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Survey

Complete our smile evaluation to find out how we can help design your perfect smile.

Step 1 of 11

9%

Name*
Email*
Phone*
Preferred Office?

I am...*
- A Teen
- An Adult
- A Parent (looking for my child)

People with straight teeth are regarded as having higher levels of:*
- Select All
- Attractiveness
- Health
- Success
- Self Esteem
- Wealth

(True/False) "I would love to have the full confidence to smile and show full, strong and white teeth"
- TRUE
- FALSE

What is Your Primary Goal?**
- Fix an overbite
- Fix an underbite
- Fix a crossbite
- Fix a gap
- Fix a crowding issue
- Straighter teeth in general

What appliance were you hoping to get treated with?*
- Least expensive
- Invisalign
- Open to options

How URGENT is it for you to take care of this?*
- Immediately! As soon as possible...
- Later this week
- Next week
- In the next 30 days
- Not very urgent

What's kept you from getting your smile fixed?*
- Nothing! I am ready right now
- Been to other dentists and they were too expensive
- Haven't found an orthodontist I'm comfortable with

Insurance normally covers only a small portion of orthodontic treatment. The majority of costs will need to be paid out of pocket or through financing. Will you move forward with treatment?*
- Yes
- No

Ortho Treatment can be a significant financial investment. Please describe your financial investment needs to better help us assist you*
- I am paying in cash for full treatment
- I can pay a portion of treatment , but will need additional financing
- I cannot pay any of the treatment costs and will need full financing

Upon receiving your evaluation we will contact you to schedule a date and time for your consultation. Do you commit to showing for your appointment ?*
- Yes, I commit to showing up for my consultation on time.
- NO

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