What best describes your current dental condition?
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I have all my teeth, but they are failing
I’m missing one tooth
I’m missing multiple teeth
I’m missing all of my teeth
I wear dentures or partials
How has your dental condition affected your life? (Select all that apply)
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Difficulty eating certain foods
Pain or discomfort
Avoiding social situations/photos
Feeling older than I am
It affects my health or daily life
What is your biggest reason for wanting treatment now?
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I want to eat normally again
I want to feel confident smiling
I’m tired of dentures or loose teeth
I want a long-term solution
I’ve finally decided to prioritize myself
Have you seen another dentist or implant office about this before?
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No, this is my first consultation
Yes, but I did not feel comfortable
Yes, I’m comparing options
Yes, but treatment was too expensive
What has stopped you from moving forward previously?
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Cost
Fear or anxiety
Time
I couldn’t find the right office
I wasn’t ready until now
How soon are you hoping to improve your smile?
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Immediately
Within 1–3 months
Within 6 months
I’m still researching options
If you qualify for treatment, how are you most likely planning to pay?
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Savings/personal funds
Financing/monthly payments
Combination of savings and financing
401(k), retirement, or investments
Help from family/spouse
I’m not sure yet
Are you interested in learning about financing or monthly payment options?
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Yes
No
Maybe depending on cost
Which range best represents your self-reported credit score?
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Below 550
551–600
601–650
651–700
701+
Not sure
Some financing programs may require a co-signer for the best approval options. Would you have someone available to assist if needed?
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Yes, I have someone who would cosign
Possibly
No, I would apply alone
I have other payment options available
What matters most to you in choosing the right implant office?
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Trust in the doctor/team
Affordable payment options
Experience with full-mouth implants
Natural-looking results
Fast treatment timeline
What would a successful smile transformation mean for you personally?
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Eating without worry
Smiling confidently again
Feeling younger and healthier
Improving my quality of life
Feeling comfortable around others
All of the above
First Name
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Last Name
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Postal Code
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Phone
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Email
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