Form

1

What Is Your Full Name?* This field is required.

First Name

Last Name

2

Best Mobile Number

Please enter a valid phone number.

3

What Is It About Your Smile You Want To Fix?* This field is required.

4

How Long Has This Been A Problem?* This field is required.

5

What Have You Done To Try To Fix This In The Past?* This field is required.

6

What Happened To Make You Want to Fix This Problem Now?* This field is required.

7

Why Is it Important For You To Fix This Now?* This field is required.

8

If You See Your Treatment Plan & You Believe It Will Give You The Smile You've Always Wanted, How Soon Would Want To Begin Treatment?* This field is required.

I'm Ready To Start Now

I'm Ready To Start In 2 Weeks

I'm Ready To Start This Month

I'm Ready To Start This Quarter

9

Let's Pretend You Move Forward With Treatment, Would You Prefer A Monthly Payment Plan?* This field is required.

YESNO

10

Understanding That This Is An Investment In Your Smile & Yourself, Do You Have Access To A Minimum Of $3,000 To Be able To Start Treatment If It Will Get You The Smile You Want?* This field is required.

YESNO

11

Again, Let's Pretend You Move Forward With Treatment, Are You Prepared To Follow Your Treatment Plan To The Letter To Ensure Your Results Match Your Expectations?* This field is required.

YESNO