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

Email *

Phone *

First Name

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