What Best Describes Your Current Gum and Oral Health? *

Bleeding Gums During Flossing Or Brushing

Red, Swollen, Or Often Bleeding Gums

Receding Gums Or Loose Teeth

Other

Please Specify Your Current Condition *

SELECT ALL THAT APPLY - Have You Noticed Any Of The Following? *

Bad Breath or A Bad Taste

Loose Or Shifting Teeth

Tooth Pain

No, I Haven’t Noticed Any of The Above Issues

How Long Has It Been Since Your Last Dental Cleaning or Exam? *

Less than 6 Months

6 Months to 1 Year

Over a Year

Have You Seen Another Dentist About Periodontal Issues Lately? *

No, This Is My First Consultation

Yes, I've Spoken To Another Periodontist

Yes, I Was Advised By My Dentist

Why Are You Seeking Another Opinion? *

I Want to Confirm the Diagnosis or Treatment Plan.

I Want to Explore Other Treatment Options.

The Cost of Treatment Was Too High.

What Did Your Previous Dentist or Periodontist Recommend? *

A Deep Cleaning (Scaling and Root Planing).

Gum Surgery or Laser Treatment.

Gum Grafting or Tissue Repair.

Tooth Extractions or Implants.

Not Sure

For Your Convenience, We Will Send You The Customized Information In Regards To Pricing For Periodontal Care Via Text And Email *

Yes send me the information

No, I do not wish to receive information regarding pricing for dental implants

By Selecting No, We Have No Immediate Way To Send You The Information That You Are Requesting. *

Yes I consent to receive this information

I would like to schedule an appointment to talk in person

I would like to speak to someone via phone call to discuss

I do not want this information

Our Practice Is Located In Linden, NJ. Are You Willing To Travel To This Location? *

Yes

No

Is There Anything Else You'd Like Us To Know About Your Periodontal Needs Or Concerns?

First Name *

Last Name *

Postal Code *

Phone *

Email *

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