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Delafield Dental - Implant Survey (Eval)
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
How Long Have you Been Living with Tooth Loss?
*
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0-2 Years
3-5 Years
5-10 Years
Over 10 Years
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3
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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4
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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5
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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6
Have you had a consultation or treatment plans from other dentists for dental implants?
*
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Yes
No
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7
Upon credit approval or with the help of a cosigner, payment plans are available! Which best describes your credit?
*
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(Very Poor) Under 500
(Poor) 500-649
(Good) 650-749
(Excellent) 750+
I don’t know
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8
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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First Name
Last Name
Phone Number
Email
Please Select
Internet
Google
Facebook
TV
Radio
Friend/Family
Doctor
Print
Other
Please Select
Please Select
Internet
Google
Facebook
TV
Radio
Friend/Family
Doctor
Print
Other
How Did You Hear About Us?
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9
Get Page URL
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10
gclid
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11
fbclid
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