First - Some Info About You!
Are You Currently Wearing Dentures?
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Yes - Full Dentures
Yes - Partial Dentures
No
What Best Describes Your Condition?
I have an upper denture
I have a lower denture
I have both an upper & lower denture
Other Condition
How Long Have You Been Missing Your Teeth?
I'm Not Missing Teeth
Less Than A Year
More Than A Year
What Is The Most Important Factor That Has Stopped You From Getting Treatment Previously?
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Time
Money
Fear
Can't Find The Right Dentist
How Fast Are You Looking To Change The Way You Smile?
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1 - Very Little, I'm Not In A Rush
2- Moderate, I-3 Months
3 - High, I'm Looking For Help Now!
Have You Seen Another Dentist About Your Condition?
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No, This is my first consultation
Yes, I did not feel comfortable with the other practice
Yes, I'm looking to compare pricing
Considering this special offer, are you interested in learning more about how our financing options can help make the remaining cost of your new dental implants affordable?
Yes
No
To help us determine the best financing options for you, which range best represents your credit score?
500 - 550
551 - 600
601 - 650
651 - 700
701+
Is There Anything Else You Would Like Us to Know About Your Dental Needs or Concerns?
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Second - Making Sure We Can Talk!
For Your Convenience, We Will Send You Customized Information In Regards To Your Denture Rebate And Dental Implants Via Text
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Yes send me the information
No, I do not wish to receive information regarding pricing for dental implants
By Selecting No, We Have No Immediate Way To Send You The Information That You Are Requesting.
Yes I consent to receive this information
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 information
Third - Scheduling Your Appointment!
Our Practice Is Located In Sylacauga, AL. Are You Willing To Travel To This Location?
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Yes
No
To Qualify & Save $4000* - Choose A Day That Works Best For You
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First Name
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Last Name
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Zip Code
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Phone
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Email
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