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

How long have you been missing your teeth? *

I'm Not Missing Teeth

Less Than A Year

More Than A Year

Do you currently have any of the following treatments? *

Crowns and/or Bridges

Partials

Dentures

None of the above

Have you experienced any type of insecurities regarding the way your teeth look? *

Yes

No

Does your condition have a negative impact on your ability to eat or chew certain foods? *

Yes

No

What is the most important outcome you are seeking? *

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? *

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? *

1 - Very Little, I'm Not In A Rush

2 - Moderate, 1-3 Months

3 - High, I'm Looking For Help Now!

Have you had treatment plans from other doctors for dental implants recently? *

Yes

No

Are you the decision maker in regards to your dental & healthcare? *

Yes

No

Which best describes your current credit score? *

499 Or Under

500-599

600-699

700+

I'm Not Sure

First Name *

Last Name *

Phone *

Email *

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