What Best Describes Your Condition? *

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? *

Yes

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: *

Personal Life

Professional Life

Enjoyment of Food

Physical Comfort

Oral Health

Appearance/Self Confidence

Have You Seen Another Dentist About Restorative Dentistry? *

No, This is my first consultation

Yes, I did not feel comfortable with the other practice

Yes, I'm looking to compare pricing

What Kind of Treatment(s) Are You Most Interested In?

Full Arch Implants

Single Implants

Dental Veneers

Crowns/Bridges

Teeth Whitening

What Is Your Primary Issue With Your Smile Right Now? *

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? *

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? *

Yes

What Is Your Most Desired Outcome In A Smile Restoration? *

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? *

Very little, I'm in no rush

Moderate, Within 1-3 months

High, I need help now

Are You Interested In Learning About Financing Options?

Yes

Which option most closely represents your credit score? *

500 - 550

551 - 600

601 - 650

651 - 700

701+

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

Yes, that is okay

No, I do not wish to be communicated via text or email

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

Yes, I consent to receiving texts

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

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

Yes

Is There Anything Else You Would Like Us to Know About Your Dental Needs or Concerns? *

First Name *

Last Name *

Postal Code *

Phone *

Email *