New Patient Smile Assessment

1

Which Condition Best Describes You?* This field is required.

1) Missing One Tooth

2) Missing Multiple Teeth

3) Struggling With Traditional Dentures

4) Most Of My Teeth Are In Bad Shape

5) Suffering from Dental Pain or Discomfort

6) Suffering from Dental Infection(s)

2

Do You Currently Have Any Of These Dental Solutions?* This field is required.

1) Partial Denture or Complete Denture

2) Dental Implants

3) Bridge Crown

4) None Of The Above

3

How Long Have You Been Missing Your Teeth? (The Longer Teeth Are Missing, The More The Jawbone Shrinks.)* This field is required.

1) I Still Have Them

2) 1-3 Months

3) 3-6 Months

4) 6 Months to 1 Year

5) 1-5 Years

4

Payment plans are available based on credit approval of the patient or a co-signer. Which best describes your credit?* This field is required.

1) Excellent (720+)

2) Good (680-720)

3) Fair (620-680)

4) Below Fair (600-620)

5) Poor (Below 599)

5

Full Name* This field is required.

First Name

Last Name

6

Email* This field is required.

example@example.com

7

Phone Number* This field is required.

8

When is the best time to contact you?* This field is required.

1) Morning (9-12 Am)

2) Afternoon (12-5 PM)

3) Evening (5-8 PM)

9

Referrer