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- Step 1 of 11

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, I-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

Name *

First

Last

Phone *

Email *

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