Extractions Assessment

1

Tell Us About Your Condition* This field is required.

2

Do You Have Any Missing Teeth?* This field is required.

Yes

No

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

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

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)