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
How Long Have You Been Missing Your Teeth?
I'm Not Missing Teeth
Less Than A Year
More Than A Year
Do You Currently Have Any Of The Following Treatments?
Crowns and/or Bridges
Partials
Dentures
None of the Above
Have You Experienced Any Type Of Insecurities Regarding The Way Your Teeth Look?
Yes
No
Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods?
Yes
No
What Is The Most Important Outcome You Are Seeking?
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?
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?
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?
Yes
No
Are You The Decision Maker In Regards To Your Dental & Healthcare?
Yes
No
Are You Interested in Learning About Our Easy Monthly Payment Plans? If So, What Dollar Range Would You Like To Pay Monthly
No Financing
$50-149/Month
$150-$249/Month
$250-349/Month
Over $350/Month
Which Best Describes Your Current Credit Score?
Below 580
580-699
700+
I'm Not Sure
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Last Name
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Phone
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Email
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