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 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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Very Little, I'm Not In A Rush
Moderate, 1-3 Months
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
First Name
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Last Name
*
Cell Phone
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Email
*