At this consultation, we will assess your smile and
determine the best treatment options for you.

First Name:
Last Name:
Date of Birth (dd/mm/yy):
Address:
City/Town:
Home Phone:
Email Address:
Last dental cleaning date:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 12345678910111213141516171819202122232425262728293031 200120022003200420052006200720082009201020112012201320142015 select
If you could change your smile, you would:
Make your teeth brighter Make your teeth straighter Close spaces Replace black metal fillings with natural, tooth coloured fillings Repair chipped teeth Replace missing teeth Replace old crowns that do not match Have a smile makeover
What is the most important thing to you about your future smile and dental health?
Any concerns or additional information that you think we should know:
Please check any of the following problems that may apply to you.
Sensitivity (hot, cold and/or sweet) Tooth pain or discomfort while chewing Headaches, earaches or neck pain Jaw joint pain (clicking/cracking) Teeth or fillings breaking Grinding or clenching teeth None Bleeding, swollen or irritated gums Loose, tipped or shifting teeth Bad breath or bad taste in your mouth
Please select the most convenient office:
Aurora Brooklin Cambridge Guelph North Guelph South East Gwillimbury Newmarket Oshawa Rosedale Scaroborough Waterloo
Picture Upload: In order to complete your smile analysis Dr. Gelfand requires a picture of your smile.