What Best Describes Your Condition?
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I Have All My Teeth
I'm Missing One Tooth
I'm Missing Multiple Teeth
I'm Missing All My Teeth
How Long Have You Been Missing Your Teeth?
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I'm Not Missing Teeth
Less Than A Year
More Than A Year
Do You Currently Have Any Of The Following Treatments?
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Crowns and/or Bridges
Partials
Dentures
None of the Above
Have You Experienced Any Type Of Insecurities Regarding The Way Your Teeth Look?
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Yes
No
Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods?
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Yes
No
What Is The Most Important Outcome You Are Seeking?
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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?
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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?
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1 - Very Little, I'm Not In A Rush
2- Moderate, 1 - 3 Months
3 - High, I'm Looking For Help Now!
Have You Had Treatment Plans From Other Doctors For Dental Implants Recently?
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Yes
No
Are You The Decision Maker In Regards To Your Dental & Healthcare?
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Yes
No
Are You Interested in Learning About Our Easy Monthly Payment Plans? If So, What Dollar Range Would You Like To Pay Monthly
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No Financing
$50-149/Month
$150-$249/Month
$250-349/Month
Over $350/Month
If you require financing, please select the option below that best describes your credit history.
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Poor Credit (Under 650)
Average Credit (650-700)
Good Credit (700-750)
Great Credit (750+)
Should you have difficulty getting approved for financing, do you have a co-signer to help you?
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Yes, I have a Co-Signer.
No, I don't have a Co-Signer.
Not Applicable - I have at least a 650 credit score, therefore I don't need a Co-Signer.
Full Name
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Email
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Phone
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