Please Describe Your Condition *

What dental issue are you most concerned about? *

Crooked teeth

Stained teeth

Broken or chipped teeth

Missing teeth

Other (please specify)

Please Explain "other"

Which dental treatment are you interested in? *

Teeth Whitening

Veneers

Invisalign or Clear Aligners

Dental Crowns

Dental Implants

Other (please specify)

Please Explain "other"

How long have you been living with this? *

0-2 years

2-5 years

5-10 years

Over 10 years

Do you have Dental Insurance? *

Yes

No

Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods? *

Yes

No

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

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

How did you hear about us? *

Family / Friend

Google search

Facebook

Doctor referral

Other

Where Can We Send The Cost Estimate?

Email

Phone Call

Text

First Name *

Last Name *

Email *

Phone *

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