SECTION A – Personal & Contact Details

Full Name

Mobile Number (WhatsApp preferred)

Email Address

Age Range
18–2425–3435–4445–5455+

City / Area

How did you hear about Veritas?
Referred by a friend / familyReferred by a dentist / clinicRecommended by Cayo DentalSocial mediaGoogle / Online searchOther

SECTION B – Your Aesthetic Goals

What would you like to improve about your smile?
Please describe in your own words (e.g. colour, shape, crowding, gaps, old fillings/crowns, overall appearance).

Which area(s) of your smile are you most concerned about?
Tooth colourTooth shape or sizeTooth alignment (crooked, crowded, gaps)Old crowns or fillings that look unnaturalWorn, chipped or broken teethGum line / “gummy” smileMissing teethOther

What type of improvement are you hoping for?
A natural, subtle enhancementA noticeable but still natural changeA dramatic transformationI’m not sure, I’d like professional guidance

SECTION C – Expectations & Timeline

When would you ideally like to complete your treatment?
As soon as possible (within 2–4 weeks)Within 1–3 monthsWithin 3–6 monthsI’m flexible / not in a hurry

How important is long-term quality and aesthetics compared to speed?
I prioritise long-term quality and aesthetics, even if it takes more timeI prefer a balance between quality and timeI mainly want the fastest possible result

SECTION D – Investment & Financial Perspective

How would you describe your approach to cosmetic treatment?
I prefer the highest quality and aesthetics, and I understand this is a premium investmentI prefer a balance between quality and costI am looking for the most affordable option

What is your approximate budget range for improving your smile?
Below LKR 150,000LKR 150,000 – 300,000LKR 300,000 – 600,000Above LKR 600,000I am not sure yet

Are you planning to claim this treatment through insurance, employer reimbursement, or any third-party scheme?
No, this is a personal investmentI may explore reimbursement options laterYes, I am primarily seeking treatment with claim/reimbursement support

SECTION E – Dental & Medical Background

Have you had any cosmetic dental treatments before?
NoYes, onceYes, multiple times

If yes, what treatments did you have and how was your experience?

When was your last dental check-up or cleaning?
Within the last 6 monthsWithin the last 1–2 yearsMore than 2 years agoI don’t remember

Do you have any ongoing medical conditions or are you on regular medication?
Please mention only if relevant (e.g. diabetes, heart conditions, blood thinners). Full medical history will be taken before treatment.

Do you smoke or use tobacco/betel regularly?
NoOccasionallyDaily

How would you describe your daily oral hygiene routine?
I brush twice a day and floss/use aids regularlyI brush once a day, sometimes moreMy routine is irregular / I am working on improving it

SECTION F – Commitment & Mindset

How involved would you like to be in planning your new smile?
I trust the dentist to recommend what suits me bestI’d like to discuss options and decide togetherI have a very specific idea and want to follow that closely

What matters most to you in choosing a cosmetic dental center?
Quality of work and natural resultsA calm and private environmentTime and convenienceLong-term durabilityDetailed explanations and planningOverall experience and hospitality

Is there anything you are worried or anxious about regarding dental treatment?

SECTION G – Photos

Upload 1–3 photos of your smile

SECTION H – Consent & Disclaimer

I understand that this form is for an initial aesthetic consultation request only. Treatment plans, suitability, and costs will be confirmed after a full clinical assessment by a qualified dental surgeon.