Do you understand this offer? *

No, I thought this was free dental work/grants

Yes, I understand this is a consultation offer

How Long Have You Been Missing Your Teeth? *

I'm Not Missing Teeth

Less Than A Year

More Than A Year

How Has Tooth Loss Affected the Following Areas of Your Life? (Select all that apply) *

Personal Life

Professional Life

Enjoyment of Food

Physical Comfort

Oral Health

Appearance / Self Confidence

Have You Seen Another Dentist About Dental Implants?* *

No, This is my first consultation

Yes, I did not feel comfortable with the other practice

Yes, I'm looking to compare pricing

What Is Your Primary Issue With Your Smile Right Now? *

Tooth Pain

Missing Teeth

Insecurities about the way you look

All of the above

What Is The Most Important Factor That Has Stopped You From Getting Treatment Previously? *

Time

Money

Fear

Can’t Find The Right Dentist

Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods? *

Yes

No

What Is The Most Desired Outcome You Are Looking For From Full Mouth Rehabilitation? *

Function – Eating, Chewing, Talking

Aesthetics – Beautiful, Natural Looking Teeth

Both Are Equally As Important

How Urgently Do You Want to Change Your Smile? *

Very little, I'm in no rush

Moderate, Within 1–3 months

High, I need help now

Are You Familiar With An “All On 4” Treatment? *

Yes

No

Are You Interested In Learning About Financing Options? *

Yes

No

Which option most closely represents your credit score?* *

500 – 550

551 – 600

601 – 650

651 – 700

701+

Are You Willing to Travel to Our Practice in Toms River, NJ ? *

Yes

No

Is There Anything Else You Would Like Us to Know About Your Dental Needs or Concerns?* *

First Name *

Last Name *

Postal Code *

Phone *

Email *

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