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District Dental Group Fairfax - Implant Survey
HIPAA
Compliance
1
What
Best
Describes Your Condition?
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Broken, loose, or discolored teeth
I'm missing multiple teeth
I'm missing one tooth
I'm missing all my teeth or in dentures
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2
What is the most important outcome you are seeking?
*
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Function - Eating, Chewing, Talking
Aesthetics - Beautiful, Natural-Looking Teeth
Both are equally as important
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3
What is the most important factor that has prevented you from getting treatment?
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Time
Fear
Money
Can't find the right dentist
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4
What is your level of urgency to find a solution for your dental needs?
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Very little, I'm not in a rush
Moderate, 1-3 months
High, I'm looking for help now!
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5
Have you had a consultation or treatment plans from other dentists for dental implants?
*
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Yes
No
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6
You May Be A Candidate For Dental Implants!
Fill Out The information and Our Highly Trained Team Will Reach Out To You With Your Results!
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Full Name
Phone Number
Email
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7
Get Page URL
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