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Center for Dentistry and Orthodontics

5625 Woodland St.
Stevens Point , WI 54482

Phone: (715) 341-8335
Email: office@drwalczak.com

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Monday: 8 am - 5 pm
Tuesday: 7 am - 5 pm
Wednesday: 8 am - 5 pm
Thursday: 7 am - 5 pm

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FREE SELF-ASSESSMENT

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20%

What most motivates you to improve your smile?*
- I feel self-conscious when I speak, laugh or smile
- I have a big event coming up in my life and having a new smile for that occasion would be meaningful to me
- My career involves working in close proximity with customers or colleagues and a new smile would increase my confidence at work
- My career requires that I speak in front of large groups, improving my smile would give me more confidence

Which statement best describes what bothers you most about your smile?*
- I have spaces in between some of my teeth
- One or two of my teeth are out of position
- Some of my teeth are crooked
- Some of my teeth are crowded together
Beyond straightening your teeth, do you have any other complaints about your smile?*
- I don't like the overall shape of my teeth
- I think that I grind or clench my jaw at night and some of my teeth seem to be worn
- I would like my teeth to be whiter
- Some of my teeth seem to be too long or too short

I have previously undergone treatment with the following (select all that apply):*
- Aligner treatment
- Comprehensive orthodontics (metal braces)
- Removable orthodontic appliances
- None of the above
In the last 5 years, have you spoken with an orthodontist about your teeth?*
- Yes
- No

What areas are the most concerning to you about receiving treatment?*
- Appearance of clear braces
- Will I qualify for treatment
- Cost
- Length of treatment
What is your age range?*
- 16-24
- 25-34
- 35-44
- 45-54
- 55-64
- 65+

Name*
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