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 - Full Dentures
Yes - Partial Dentures
No
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
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 your condition?
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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 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 Prevented You From Getting Treatment?
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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 The Term "All-On-4"?
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Yes
No
Are You Interested In Learning About Financing Options?
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Yes
No
Which option most closely represents your credit score?
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500 - 550
551 - 600
601 - 650
651 - 700
701+
For your convenience, we will send you the customized information in regards to pricing for dental implants via text and email in terms of your options and timeline.
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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
Which Colorado Based Location Is Most Convenient For You?
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Aurora, CO
Westminster, CO
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Is There Anything Else You Would Like Us to Know About Your Dental Needs or Concerns?
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What Is Your Preferred Language?
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English
Spanish
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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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