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
Are You Currently Wearing Dentures?
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Yes
No
How Long Have You Been Missing Your Teeth?
I'm Not Missing Teeth
Less Than A Year
More Than A Year
Select All That Apply - Do You Feel That Tooth Loss Has Affected Your:
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Personal Life
Professional Life
Enjoyment of Food
Physical Comfort
Oral Health
Appearance/Self Confidence
Have You Seen Another Dentist About Dental Implants?
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No, This is my first consultation
Yes, I did not feel comfortable with the other practice
Yes, I'm looking to compare pricing
If you have been to a consultation recently for your current condition, what were you seen for?
Missing 1 Tooth
Full Mouth/ Upper and Lower Arch
Single Arch/ Lower OR Upper
Single Tooth
If This Is A Second Opinion What Type Of Implant Solution Are You Looking For?
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Fixed Full Arch
Implant Supported Denture
Single Implant
Traditional Denture
Not Sure
What Is Your Primary Issue With Your Smile Right Now?
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Tooth Pain
Missing Teeth
Insecurities about the way you look
All of the above
What Is The Most Important Factor That Has Stopped You From Getting Treatment Previously?
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Time
Money
Fear
Can't Find The Right Dentist
Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods?
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Yes
No
Implants Are Capable Of Changing Lives - What Is Your Most Desired Outcome In A Full Mouth Rehabilitation?
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Function - Eating, Chewing, Talking
Aesthetics - Beautiful, Natural Looking Teeth
Both Are Equally As Important
How Fast Are You Looking To Change The Way You Smile?
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Very little, I'm in no rush
Moderate, Within 1-3 months
High, I need help now
Are You Familiar With An "All On 4" Treatment?
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Yes
No
Are You Interested In Learning About Financing Options?
Yes
No
Do you have a Blue Cross / Blue Shield PPO Medical Plan?
Yes
No
Which option most closely represents your credit score?
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500 - 550
551 - 600
601 - 650
651 - 700
701+
We work with financing companies that we see approvals as low as a 660 credit score. If needed, do you have someone willing to co sign for you?
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Yes
No
If you do not have someone willing to co-sign for you, did you have another plan in place to move forward with treatment?
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
Our Practice Is Located In McKinney, TX. Are You Willing To Travel To This Location?
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Yes
No
If you would like to provide more information please provide here
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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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