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'm not interested in financing

8

What location is closest to you?* This field is required.

9

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

Zip Code

Email

How Did You Hear About Us?

10

Get Page URL

11

gclid

12

fbclid

13

SMC APP NAME

14

SMC APP NUMBER

15

SMC APP EMAIL