You can always press Enter⏎ to continue
Smart Arches Dental Implants (Jacksonville) - Implant Survey
HIPAA
Compliance
1
How Can We Reach You?
*
This field is required.
Smart Arches Dental Implant Centers is a small network of expert implant surgeons and restorative dentists. We have complete focus on helping patients with chronic dental disease faced with the prospect of losing their teeth or with patients already in dentures. That is all we do, every single day. We invite you to our office for a complimentary consultation. Just fill out the form and one of our team members will contact you shortly. We can’t wait to meet you!
First Name
Last Name
Phone Number
Zip Code
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?
Previous
Next
Submit
Press
Enter
2
Why are you interested in Smart Arches?
*
This field is required.
Select ALL that Apply
Get rid of poorly fitting dentures
My teeth are loose
Severe gum disease
Cavities or deteriorated teeth
Crowding with my teeth and/or a poor bite
It is difficult to bite or chew properly
I am embarrassed to smile
I have chronic pain from my teeth condition
I want to stop the constant cycles of failed dental treatment
Other
Previous
Next
Submit
Press
Enter
3
What has prevented you from seeking treatment until now?
*
This field is required.
Fear of the dentist
Fear of the unknown
Total investment needed for treatment
Haven’t had the time in my life
Everyone else was first. Now it’s my turn
It just hasn’t been the right time for me
Previous
Next
Submit
Press
Enter
4
OK- let’s get started! How soon do you want to get started?
*
This field is required.
I’m ready for my life-changing consultation NOW!
I plan on doing something in the near future. Let’s see.
Not really sure. But I want to get information.
Previous
Next
Submit
Press
Enter
5
Have you had a consultation for dental implants before?
*
This field is required.
Yes, but I want an expert surgeon and team for my treatment.
I have seen my general dentist for a previous consultation.
I have seen another clinic but I want a 2nd opinion.
This will be my first time seeking treatment.
Previous
Next
Submit
Press
Enter
6
Do you need financing options for your Smart Arches?
*
This field is required.
Life-changing Smart Arches treatment can be made at an affordable price without compromise to your care. We also offer several financing options if needed. Our Smart Arches Patient Ambassador will lead you through this simple process.
I do not need financing options.
I will have a family member helping me.
Yes, I have great credit and will likely be approved for excellent rates.
Yes, but my credit has some challenges. I may need some help here.
Yes, and I will likely have a cosigner to assist me with Smart Arches.
Previous
Next
Submit
Press
Enter
7
Get Page URL
Previous
Next
Submit
Press
Enter
8
gclid
Previous
Next
Submit
Press
Enter
9
fbclid
Previous
Next
Submit
Press
Enter
10
SMC APP NAME
Previous
Next
Submit
Press
Enter
11
SMC APP NUMBER
Previous
Next
Submit
Press
Enter
12
SMC APP EMAIL
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
12
See All
Go Back
Submit