Implant Survey

1

What Best Describes Your Condition?* This field is required.

Broken, loose, or discolored teeth

I'm missing multiple teeth

I'm missing one tooth

I'm missing all my teeth or in dentures

2

How Long Have you Been Living with Tooth Loss?* This field is required.

0-2 Years

2-5 Years

5-10 Years

Over 10 Years

3

What is the most important outcome you are seeking?* This field is required.

Function - Eating, Chewing, Talking

Aesthetics - Beautiful, Natural-Looking Teeth

Both are equally as important

4

What is the most important factor that has prevented you from getting treatment?* This field is required.

Time

Fear

Money

Can't find the right dentist

5

What is your level of urgency to find a solution for your dental needs?* This field is required.

Very little, I'm not in a rush

Moderate, 1-3 months

High, I'm looking for help now!

6

Have you had a consultation or treatment plans from other dentists for dental implants?* This field is required.

Yes

No

7

Upon credit approval or with the help of a cosigner, payment plans are available! Which best describes your credit?* This field is required.

(Very Poor) Under 500

(Poor) 500-649

(Good) 650-749

(Excellent) 750+

I don’t know

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!* This field is required.

First Name

Last Name

Phone Number

Email

How Did You Hear About Us?

9

Get Page URL

10

gclid

11

fbclid

12

SMC APP NAME

13

SMC APP NUMBER

14

SMC APP EMAIL