9100 Wilshire Blvd, Ste 330W.
Beverly Hills CA 90212
Tel: (310) 273.1199

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Video Testimonials

Dr. Anjali Rajpal, DMD

Dr. Rajpal considers herself a practitioner of the art of dentistry. She believes that dentistry is more than just a scientific pursuit. It requires judgment, intuition and intricate technique. She's committed to blending art and science to create healthy smiles that are both aesthetically-pleasing and functional. Because of her interest in painting and sculpture and because she enjoys working with her hands, she finds dentistry a natural fit for her.

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PATIENT INFO

Patient Name *
Email *
Are you happy with the way your smile looks? Yes No *
Are you embarrassed about smiling in front of people? Yes No *
Do you ever put your hand up to cover your smile? Yes No *
Do you dislike your smile in photographs? Yes No *
Do you have crooked, misaligned, or off-centered teeth? Yes No *
Do you wish your teeth were white? Yes No *
Do you have gaps or spaces between your teeth? Yes No *
Are you considering braces for that perfect smile? Yes No *
Do you show your gums when you smile? Yes No *
Would you like to change the way your teeth or gums are shaped? Yes No *
Do you have missing teeth? Yes No *
Would you like to have your mercury amalgam fillings changed to tooth colored restorations? Yes No *
How would you rate your smile on a scale of 1-10
Are you aware of the new techniques in cosmetic dentistry? Yes No *
What, if anything, about your teeth or smile would you like to change?

 

Fields with ( * ) are required.