What Best Describes Your Current Condition?
*
I'm missing a tooth
I'm missing multiple teeth
I'm missing all of my teeth
I'm not missing any teeth.
How long have your teeth been missing
Less than 1 year
N/A I am not missing teeth
Over 1 year
What (if any) dental treatment have you previously tried?
Crowns/Bridges
Removeable Dentures
Partials
Do you feel self conscious about your smile?
Yes
No
Do you struggle to eat or chew foods because of your current oral health condition?
Yes
No
What aspect(s) are most important to you for your smile?
Ability to Eat & Chew
Ability to Talk Properly
Good Oral Health
Easy to Take Care Of
A Bright, White Smile
Natural Looking Teeth
What has prevented you from getting treatment?
Cost of treatment
Time needed
Fear/Anxiety
Can't find the right dentist
Other
What level of urgency do you have to solve your oral health issues/pain?
Low - I'm not in a rush
Moderate - I'm looking to get started soon
High - I need help ASAP
Have you previously received a treatment plan for dental implants?
Yes
No
Are you the primary decision maker in regard to your dental and healthcare needs?
Yes
No
First Name
*
Last Name
*
Phone
*
Email
*
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