Are You Unhappy With the Appearance of Your Smile?
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Yes
No
Are You Currently Experiencing a Lack of Confidence in Social Situations or Find Yourself Hiding Your Smile?
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Yes
No
What Are Some of the Things You Would Like to Improve About Your Smile?
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Missing Teeth - I need to replace my missing teeth.
Stained Or Unattractive Teeth - I want my teeth to look attractive.
Tooth Alignment - My teeth are not straight.
Looking for a Smile Makeover
Nothing, I'm happy with my smile.
What Is the Biggest Problem That You’re Having With Your Teeth Right Now:
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I'm missing 1-2 teeth
I’m missing more than 2 teeth
I have chips or cracks visible in my smile
My teeth have gaps (large or small) or crowding.
How Important Is Preserving Your Natural Tooth Enamel?
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Mandatory with no exceptions.
Very important - I want to keep my natural teeth as natural as possible.
I don’t mind losing some enamel in the process if it means improving my overall smile.
What Has Kept You From Getting Your Smile Fixed?
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Nothing! I'm Ready Right Now!
Fear of Dental Procedures
Cost of Dental Procedures
Time Involved in Dental Procedures
I Haven't Found A Dentist I'm Comfortable With Yet
If You Could Fit Smile Makeovers Into Your Budget Are You Ready to Start Right Away?
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Yes
No
How Quickly Do You Want Results?
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As soon as possible. I don’t want to have to wait for a better smile any longer than I already have
I don’t mind waiting if it means better, longer-lasting results
As soon as I have gathered all of the information necessary to make the best decision
Have You Had Treatment Plans From Other Doctors for Smile Makeovers Recently?
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Yes
No
Do You Have Any Significant Damage to Your Teeth Such as Deep Decay?
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Yes, but only in my back teeth
Yes, in my front teeth
No
Do You Have Healthy Dental Enamel?
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No, in the past I have or currently have suffered from enamel erosion
Yes
I’m not sure
What Is the Most Important to You When Selecting a Dental Health Provider?
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Financing Options
Experience & Level Of Expertise
Flexibility Of Appointment Times
Price
Do You Understand That Medicare and Medicaid Do Not Cover Cosmetic Dentistry, and Most Insurances Do Not Provide Coverage for Cosmetic Dentistry?
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Yes
No
Approximately What Investment Range Are You Comfortable With?
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$1,500 - $4,000
$4,000 - $10,000
$10,000 - $20,000
$20,000 - $50,000
Not sure yet. Need to schedule my consultation
Are You Interested in a Payment Plan Option? Many Affordable Payment Plan Options Exist as Little as $65/MO for a Single Tooth or $260/MO for a Full Smile Makeover
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Yes, I'm Interested In Affordable Payment Plan Options
No, I Will Not Need A Payment Plan
Payment Plans Are Available Based on Credit Approval of the Patient or a Co-signer. Which Best Describes Your Credit?
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(Very Poor) Under 500
(Poor) 501-600
(Good) 601-649
(Very Good) 650-699
(Excellent) 700+
I don't know
Based on Your Credit Score You May Not Qualify for Financing Without a Co-signer. Do You Have Someone With Good Credit History Who Would Co-sign With You?
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Yes
No
Before Taxes, What Is Your Estimated Household Income?
Click Here to Select Your Estimated Household Income
Under $12,000
$12,000 - $23,999
$24,00 - $35,999
$36,000 - $49,999
$50,000 - $69,999
$70,000 - $94,999
$95,000 +
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Unfortunately, It Looks Like You Would Not Be Able to Qualify for Our Payment Plan Options. Do You Have Any Other Way to Pay for a Cosmetic Dental Procedure?
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Savings
Credit Card
Retirement Account
Other Loan (Home Equity, etc)
Help From A Relative
No, I Don't
What City and State Do You Live In?
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City
State
Last Step
Please Use the Form Below to Complete Your Questionnaire and Claim Your Special Offer on Cosmetic Dentistry!
Full Name
*
What Is Your Best Email Address?
*
What Is Your Best Phone Number?
*
Best Time To Contact You?
Best Time To Contact You?
Morning
Afternoon
Evening
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