What best describes your current condition?
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I have all of my teeth
I'm missing one tooth
I'm missing multiple teeth
I'm missing all of my teeth
How Long Have You Been Missing Your Teeth?
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Which of the following treatments do you currently have?
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Crowns and/or Bridges
Partials
Dentures
None of the above
When was the last time you were seen by a dentist?
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Are you currently in any pain?
Yes
No
Are you experiencing any type of insecurities regarding the way your teeth look?
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Yes
No
Does your condition have a negative impact on on your ability to eat or chew certain foods?
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Yes
No
What is your desired outcome?
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What's the most important factor preventing you from seeking treatment?
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Time
Money
Fear
Can't Find The Right Dentist
What's your level of urgency to find relief from any pain or discomfort?
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Very Little, I'm Not In A Rush
Moderate, I-3 Months
High, I'm Looking For Help Now!
Have you been treated by any Dentists for implants recently?
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Yes
No
Dental Implant procedures are not covered by insurance. However, many affordable payment plans are available. Are you interested in a payment plan option?
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Yes. I'm interested in affordable payment plan options.
No. I am aware of the potential cost for implants and will not need financing options.
Which of the options below most accurately represents your current credit score?
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(Excellent) 750+
(Good) 650-749
(Fair) 600-649
(Poor) Under 599
Do you own your own home?
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Yes
No
Which best describes your current household monthly income?
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Over $8,000
$4,000 to $8,000
Under $4,000
Which location is closest to you?
Select the Location Closest To you
Draper, UT
Gilbert, AZ
Other
First Name
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Last Name
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Email
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Phone
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