Have You Been To Any Other Consultations About Your Teeth? *

No, This Is My First Consultation

Yes, I'm Looking For A Second Opinion

Yes, I Didn't Feel I Could Trust The Office/Doctor

Yes, I'm Looking To Compare Pricing

Do You Have A Trip, Wedding, Birthday, Or Special Event Coming You're Hoping To Fix Your Teeth Before? *

Yes

Please Describe Your Current Oral Health And Some Of The Challenges You Are Experiencing: *

Have You Had Any Bad, Painful, Or Traumatic Dental Experiences In The Past That Have Caused You To Avoid Treatment? *

Yes

Monthly Payment Plans Are Available. Are You Thinking Of Using Financing To Pay For A Portion Of Your Treatment? *

Yes

Our Current Payment Plan Options Are Based On Credit Approval. What Is Your Best Estimate Of Your Credit Score? *

Under 620

Over 620

Over 700

I Don't Know My Credit Score

If Needed, Do You Have Any Loved Ones Who May Be Willing To Help Financially As A Cosigner? *

Yes

Maybe

First Name *

Last Name *

Phone *

Email *

Postal Code *

Our Office Is Located In Jacksonville, FL. Are You Willing To Travel To Our Location For Treatment? *

Yes

Hotel Accommodations & Car Service Provided On Day Of Surgery For Full Arch Patients Who Live Two Or More Hours Away.

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This is NOT an offer for free dental implants or free / paid dental implant trials.

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Complete This Survey To Receive An Email Containing The Following:

Office Phone Number: 904.355.5531

Texting Phone Number: 904.561.5999

1061 Riverside Avenue, Jacksonville, FL 32204

Mon - Thurs: 8:00AM - 5:00PM & Fri: 9:00PM - 3:00PM