How Many Teeth Are You Looking to Replace?
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Single tooth
Several teeth
Full mouth
I'm not missing teeth
How Long Have You Been Missing Your Teeth?
Less than a year
More than a year
Have You Considered Dental Implants Before?
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Yes, I’m seriously considering them
Yes, but just exploring
No, this is my first time
What Has Held You Back from Moving Forward with Dental Implants?
Cost
Fear of surgery
Unsure if I’m a candidate
What Matters Most to You in A Tooth Replacement Solution?
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Long-lasting results
Natural look and feel
Comfort while eating/speaking
Cost/Affordability
How Soon Are You Looking to Move Forward with Treatment?
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As soon as possible
Within 3 months
Within 6–12 months
Just researching
Are You Interested In Learning About Financing Options?
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Yes
No
Not Sure
Which option most closely represents your credit score?
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Excellent (720+)
Good (660–719)
Fair (600–659)
Needs improvement (below 600)
Not sure
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 Fort Lauderdale, FL. Are You Willing To Travel To This Location?
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Yes
No
Is There Anything Else You Would Like Us to Know About Your Dental Needs or Concerns?
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What Language Is Most Convenient For You?
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English
Spanish
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