Survey

Please complete our survey to receive a coupon for a
FREE examination and cleaning OR $50 off any recommended treatment following complete examination and x-rays.

* indicates required fields

Last Name *
First Name *
Address *		Apt. #
City *
State *
Zip *
E-mail *

In which area do you reside (if not listed, choose the closest city or area) *:

Your age: *

Gender: *

Which describes your current dental interests? (check all that apply)

Composite Fillings (tooth colored fillings)
Tooth Whitening (bleaching)
Porcelain Veneers
Porcelain Crowns
Dentures
Implants
Check-up

Please answer the following questions about your dental experience and attitudes toward dental treatment:

My previous dental treatment experience has been positive overall. *
My previous dental treatment experience has been more negative than positive. *
I'm happy with the appearance of my teeth. *
Having to miss work time usually prevents me from completing dental treatment. *
Fear of pain usually prevents me from seeking dental treatment. *
Cost is usually the most important factor as I decide between several treatment options. *

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