Cosmetic Analysis

For a cosmetic analysis, simply complete the form below and someone from our dental team will contact you soon.


Do you have concerns about? (please check all that apply)

Gaps or Spaces between Teeth
Color of Teeth
Shape of Teeth
Size of Teeth
Show too much Gum
Symmetry of Teeth
Position of Teeth (crooked or crowded)
Teeth Chipped or Broken
Discolored Restorations (i.e. existing crowns, fillings, bonding)
Front Teeth
Back Teeth
Inflamed or Bleeding Gums



What do you like best about your smile?

What do you like least about your smile?

Your Name:
Your Email Address:
Comments or Questions:



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Now Open 7
Days a Week!


New Patient Offer

 
Welcome Dental Exam $1
Includes exam, full set of xrays
and treatment consultation.
(value of $250)

 
Welcome Back Dental Exam $1
Includes exam and FMX xray
With cleaning $91.

(Must be a patient who has not been in our office within  the last two years)

 
Complete the form below by the deadline.

 
 
Offer expires: 02/08/2012

 


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Hercules Dental Care · Douglas Lin D.D.S. & Associates
500 Alfred Nobel Drive · Hercules CA, 94547

 

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