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Pflugerville Family Dentistry - Smile Makeover Survey
HIPAA
Compliance
1
What Would You Like to Change About Your Smile?
*
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Chipped/Cracked
Coloration
Crooked
Worn Down
Size/Symmetry
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2
Approximate Number of Teeth Needing Veneers?
*
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1-3
3-6
All Top
Bottom
Top and Bottom
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3
What Are the Most Important Factors To You In Choosing a Cosmetic Dentist?
*
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Experience
Cost
Quality of Results
Technique
Timeframe
Technology
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4
Are You Interested in Financing Options?
*
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Yes
No
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5
What Is Your Timeline For Starting Treatment?
*
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ASAP
2-4 weeks
6-8 weeks
more than 8weeks
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6
Anything Else That You Would Like For Us to Know Regarding Your Smile?
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7
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
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Please Select
Internet
Google
Facebook
TV
Radio
Friend/Family
Doctor
Print
Other
How Did You Hear About Us?
What is the Best Time to Reach You?
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8
Get Page URL
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9
gclid
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10
fbclid
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11
SMC APP NAME
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12
SMC APP NUMBER
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13
SMC APP EMAIL
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