Are you A Candidate For LANAP?

PERIODONTAL evaluation

What Best Describes Your Symptoms? Check All That Apply*

Red, Irritated Gum Tissue/Gum Inflammation

Bleeding Gums

Bad Breath

Gum Recession

Loose or Shifting Teeth/Tooth & Bone Loss

None of the Above

How Long Have You Been Experiencing Symptoms?

I Am Not Experiencing Symptoms

Less Than A Year

More Than A Year

Have You Experienced Any Type Of Insecurities Regarding The Way Your Teeth Look? *

Yes

Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods? *

Yes

What Is The Most Important Outcome You Are Seeking?

Function - Eating, Chewing, Talking

Aesthetics - Beautiful, Natural Looking Teeth

Both Are Equally As Important

What Is The Most Important Factor That Has Prevented You From Getting Treatment? *

Time

Money

Fear

Can't Find The Right Dentist

What Is your Level of Urgency To Find Relief From Any Type Of Pain Or Discomfort That You May Be Feeling? *

1 - Very Little, I'm Not In A Rush

2- Moderate, I-3 Months

3 - High, I'm Looking For Help Now!

Are You The Decision Maker In Regards To Your Dental & Healthcare? *

Yes

Do You Require Any Transportation To & From Our Practice? *

Yes

First Name *

Last Name *

Phone *

Email *

Postal code *

I understand the information disclosed in this form may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations and the HITECH Act.

COMPLETE THIS EVALUATION TO INSTANTLY DISCOVER:

If you're a candidate for LANAP
What treatment options are available for you