What Best Describes Your Condition? *

I Have All My Teeth

I'm Missing One Tooth

I'm Missing Multiple Teeth

I'm Missing All My Teeth

Are You Currently Wearing Dentures? *

Yes

How Long Have You Been Missing Your Teeth?

I'm Not Missing Teeth

Less Than A Year

More Than A Year

Select All That Apply - Do You Feel That Tooth Loss Has Affected Your: *

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

Implants Are Capable Of Changing Lives - What Is Your Most Desired Outcome In A Full Mouth Rehabilitation? *

Function - Eating, Chewing, Talking

Aesthetics - Beautiful, Natural Looking Teeth

Both Are Equally As Important

How Fast Are You Looking To Change The Way You Smile? *

Very little, I'm in no rush

Moderate, Within 1-3 months

High, I need help now

For Your Convenience, We Will Communicate With You Via Text And Email *

Yes, that is okay

No, I do not wish to be communicated via text or email

By Selecting No, We Have No Immediate Way To Send You Information. *

Yes, I consent to receiving texts

I would like to schedule an appointment to talk in person

I would like to speak to someone via phone call to discuss

I do not want this

Our Practice Is Located In Jacksonville, FL. Are You Willing To Travel To This Location? *

Yes

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

First Name *

Last Name *

Postal Code *

Phone *

Email *