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MR Dental Aesthetics - Smile Makeover Survey
1
Are You Self-Conscious About Your Appearance Because of Your Smile?
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YES
NO
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2
What Best Describes Your Smile?
*
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SELECT ALL THAT APPLY
Crooked Teeth
Discolored Teeth
Gaps or Spaces In Teeth
Visible Fillings In Teeth
Missing Tooth/Teeth
Chipped or Broken Teeth
Other
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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
Any Questions or Comments?
If none, just leave blank.
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6
You May Be A Candidate For A Smile Makeover!
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
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7
Get Page URL
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8
gclid
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9
fbclid
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