1) What is the primary reason you're seeking dental implants?
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Pain And Discomfort
Infection
Bone loss
Most of my teeth are missing and in bad shape
Struggling with traditional dentures
Multiple missing teeth
I only have a one tooth problem
I still have my teeth and looking for general dental health
2) How long have you been in pain?
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No Pain
Less than a month
1-3 months
3-6 months
Over 6 months
3) How bad is your pain and discomfort?
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Mild
Moderate
Severe
4) Which of the following best describes your need right now?
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Immediate pain relief
Replacement of denture with teeth that I don't have to take out
I want to smile again and be confident
I want to look great for a special occasion (e.g., wedding)
Being able to eat everything I want
5) Do you need to speak to a support person or a family member before making a decision?
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Yes
No
6) Will you be using our special financing program for the treatment?
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Yes
No
7) Would you want to take a financial evaluation to see how we can best help you finance treatment? This is for the clinic's use and it would not impact your credit.
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Yes
No
8) Which best describes your credit?
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Excellent (800-850)
Good (670-799)
Fair (580-669)
Poor (300-579)
9) What would potentially stand in the way of fixing your smile?
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Financial concerns
Time constraints
Fear of dental procedures
Health issues
Other (Specify Below)
10) Please specify
11) When is the best time to contact you?
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Morning
Afternoon
Evening
Full Name
*
Date of birth
Email
*
Phone
*
Address
*
Postal code
*
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