What Best Describes Your Symptoms? Check All That Apply*
Red, Irritated Gum Tissue/Gum Inflammation
Bleeding Gums
Bad Breath
Gum Recession
Loose or Shifting Teeth/Tooth & Bone Loss
None of the Above
How Long Have You Been Experiencing Symptoms?
I Am Not Experiencing Symptoms
Less Than A Year
More Than A Year
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!
Are You The Decision Maker In Regards To Your Dental & Healthcare?
*
Yes
No
Which Best Describes Your Current Credit Score?
*
499 Or Under
500-599
600-699
700+
I'm Not Sure
Do You Require Any Transportation To & From Our Practice?
*
Yes
No
Which Type of Consultation Do You Prefer?
*
In-Office Consultation
Tele-Consultation
First Name
*
Last Name
*
Phone
*
Email
*
What Is Your Preferred Method Of Communication?
*
- Preferred Method of Communication -
Text
Phone Call
Email