What Best Describes Your Condition?
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I Have All My Teeth
I'm Missing One Tooth
I'm Missing Multiple Teeth
I'm Missing All My Teeth
How Long Have You Been Missing Your Teeth?
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I'm Not Missing Teeth
Less Than A Year
More Than A Year
Do You Currently Have Any Of The Following Treatments?
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Crowns and/or Bridges
Partials
Dentures
None of the Above
Have You Experienced Any Type Of Insecurities Regarding The Way Your Teeth Look?
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Yes
No
Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods?
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Yes
No
What Is The Most Important Outcome You Are Seeking?
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Function - Eating, Chewing, Talking
Aesthetics - Beautiful, Natural Looking Teeth
Both Are Equally As Important
What Is The Most Important Factor That Has Prevented You From Getting Treatment?
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Time
Money
Fear
Can't Find The Right Dentist
What Is your Level of Urgency To Find Relief From Any Type Of Pain Or Discomfort That You May Be Feeling?
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1 - Very Little, I'm Not In A Rush
2- Moderate, I-3 Months
3 - High, I'm Looking For Help Now!
Have You Had Treatment Plans From Other Doctors For Dental Implants Recently?
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Yes
No
Are You The Decision Maker In Regards To Your Dental & Healthcare?
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Yes
No
Most Dental Implant procedures are not covered by insurance. However we offer many payment plans that make it quite affordable and offer low monthly rates. Are you interested in a payment plan?
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Yes I am!
No I will not need a payment plan
Are You Interested in Learning About Our Easy Monthly Payment Plans? If So, What Dollar Range Would You Like To Pay Monthly
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No Financing
$100-149/Month
$150-$249/Month
$250-349/Month
Over $350/Month
Payment plans are based on credit approval, you may also bring in co-signer. If you could guess, what is your credit score?
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500- 550
551 - 600
601 - 650
651 - 700
701+
I don't know my credit score
For your convenience, we will send you the customized information in regards to pricing for dental implants via text and email
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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.
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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
First Name
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Last Name
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Phone
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Email
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Postal code
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