What Is Your Main Concern That Has Brought You to Our Office? *

What Is the Biggest Problem That You’re Having With Your Teeth Right Now: *

I'm missing 1-2 teeth

I’m missing more than 2 teeth

I have chips or cracks visible in my smile

My teeth have gaps (large or small) or crowding.

Are You Able to Eat Comfortably? *

I chew mostly on one side

I have pain when I chew

I limit the types of foods I can eat

I am able to eat comfortably

Why Haven’t You Fixed the Problem Yet? *

I haven’t found a dentist I trust

I haven’t had time

The solutions I’ve found are too expensive

What Would Be the Biggest Benefit if We Could Help You Fix This Problem? *

I could smile with confidence again

I could eat normally again

My teeth wouldn’t hurt anymore

Are You Currently Experiencing a Lack of Confidence in Social Situations or Find Yourself Hiding Your Smile? *

Yes

What Are Some of the Things You Would Like to Improve About Your Smile? *

Missing Teeth - I need to replace my missing teeth.

Stained Or Unattractive Teeth - I want my teeth to look attractive.

Tooth Alignment - My teeth are not straight.

Nothing, I'm happy with my smile.

Have You Visited the Dentist in the Last Year?*

Yes

How Determined Are You to Get Rid of This Dental Problem, on a Scale of 1-10 (10 Being the Highest)

If This Is Your Second Consultation Please Explain Why You Would Like a Second Opinion? *

This is my first consult.

I did not feel confident in the doctor at the other practice.

I did not feel comfortable at the other practice.

I would like to compare prices.

What Are You Expecting to Solve When You Are Going to Meet With the Doctor? *

Major Dental Implant Treatment May Require a Substantial Financial Investment. Have You Planned on How You Will Pay for the Work Needed? *

I have good credit and would like financing arrangements.

I will pay out of pocket.

I do not have great credit and will need other financial assistance.

I have not given thought to this.

Do You Currently Have Any of the Following Treatments? *

Crowns and/or Bridges

Partials

Dentures

None of the above

What City and State Do You Live In? *

City
State

Last Step

Please Use the Form Below to Complete Your Questionnaire and Claim Your Special Offer on General Dentistry!

First Name *

Last Name *

What Is Your Best Email Address? *

What Is Your Best Phone Number? *

Best Time To Contact You?