Please Describe Your Condition
How long have you been living with this?
0-2 years
2-5 years
5-10 years
Over 10 years
Select All That Apply - Do You Feel That Your Condition Has Affected Your:
Personal Life
Professional Life
Enjoyment of Food
Physical Comfort
Oral Health
Appearance/Self Confidence
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 would like to see?
Function - eating, chewing, talking
Aesthetics - beautiful, natural-looking teeth
Both are important
What has kept you from getting treatment?
Time
Fear
Money
Can’t find the right dentist
How urgent is it for you to fix this problem?
I’m not in a rush
Within 1-3 months
I want help now
Have you consulted with another dentist on this issue?
Yes
No
Which best describes the best way for you to pay for treatment?
Dental insurance
Credit card
Check or debit card
Care credit
How did you hear about us?
Family / Friend
Google search
Facebook
Doctor referral
Other
Choose Best Time To Call
Choose Best Time To Call
Morning (8 am to 12 pm
Afternoon (12 pm to 4 pm)
Evening (4 pm to 8 pm)
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Last Name
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