Quiz Funnel Form For Blue Door Dental

Ready for a Smile Upgrade?

Take the 2-Minute Quiz to Find Out.

When was your last dental visit?*

Within the last 6 months6–12 months agoOver a year agoI honestly can’t remember

Do you have any current concerns with your smile?

Missing teethCrooked or shifting teethStained or discolored teethBleeding gums or bad breathJaw pain or headachesI just want a checkupI’m not sure—but I’d like an expert to take a look

How important is comfort during your dental visit?*

Very important – I’ve had bad experiences beforeI don’t love the dentist, but I can manageI’m fine as long as things are explained wellI’m relaxed either way

How soon would you like to be seen?*

As soon as possibleWithin the next weekIn the next monthJust gathering info for now

What are you looking for in a dental office?*

A long-term dental homeAdvanced technology and efficient careA gentle, judgment-free teamA complete smile transformationI’m not sure yet—just exploring

Would you be interested in a FREE virtual smile consultation?*

Yes! I’d love personalized feedbackMaybe—I have a few questions firstNot right now

Upload a picture of your smile*

Cancelof

Your Results Are Ready!
Just one more step to get your personalized smile insights from our expert team.

💙 We’ll also send you info on our $150 New Patient Experience (includes 3D scan, cleaning, full exam, and more!)
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Patient Details
Name*
Mobile Number
Email Address*
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