Which condition best describes you?
Which condition best describes you?
Chipped Teeth
Crooked Teeth
Gaps
Misshaped Teeth
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Which Treatment Option Are You Most Interested In?
Which Treatment Option Are You Most Interested In?
New Patient Special
Porcelain Veneers/Lumineers
ClearCorrect
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Do you currently or have had any dental solutions? (If yes, please describe what and when it was done)
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
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?
Text
Phone Call
Email