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? *

Very Little, I'm Not In A Rush

Moderate, 1-3 Months

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

First Name *

Last Name *

Cell Phone *

Email *

I agree to the terms & conditions provided by Hermann Park Smiles. By providing my phone number, I agree to receive text messages from Hermann Park Smiles.