[et_pb_section fb_built=”1″ admin_label=”Contact Info” _builder_version=”4.22.0″ background_enable_image=”off” background_size=”initial” background_position=”top_center” custom_padding=”0px||0px||false|false” global_colors_info=”{}”][et_pb_row custom_padding_last_edited=”on|desktop” _builder_version=”4.22.0″ background_color=”#e0ba42″ max_width=”1280px” module_alignment=”center” custom_margin=”|||” custom_padding=”70px|5vw|70px|5vw|true|true” custom_padding_tablet=”|5vw||5vw||true” custom_padding_phone=”|5vw||5vw||true” animation_direction=”top” border_radii=”|||14vw|14vw” use_custom_width=”on” custom_width_px=”1280px” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.16″ custom_padding=”|||” custom_padding_tablet=”40px|||” custom_padding_phone=”20px|||” custom_padding_last_edited=”off|desktop” global_colors_info=”{}” custom_padding__hover=”|||”][et_pb_text _builder_version=”4.21.0″ text_font=”Open Sans||||||||” text_text_color=”#172a54″ text_line_height=”2em” link_font=”|700|||||||” link_text_color=”#172a54″ header_font=”||||||||” header_2_font=”||||||||” header_2_text_color=”#172a54″ header_2_font_size=”40px” header_2_line_height=”1.4em” header_3_font=”Cantata One||||||||” header_3_text_color=”#0081ff” header_3_font_size=”20px” header_3_line_height=”1.6em” text_orientation=”center” background_layout=”dark” header_2_font_size_tablet=”35px” header_2_font_size_phone=”25px” header_2_font_size_last_edited=”on|phone” locked=”off” global_colors_info=”{}”]

All-On-X Dental Implants – Pre-Consult Survey

[/et_pb_text][/et_pb_column][/et_pb_row][/et_pb_section][et_pb_section fb_built=”1″ _builder_version=”4.16″ global_colors_info=”{}”][et_pb_row _builder_version=”4.24.0″ _module_preset=”default” hover_enabled=”0″ global_colors_info=”{}” sticky_enabled=”0″][et_pb_column type=”4_4″ _builder_version=”4.24.0″ _module_preset=”default” global_colors_info=”{}”][et_pb_contact_form _builder_version=”4.24.0″ _module_preset=”default” _unique_id=”e1c7bc47-8dcb-48e1-b15b-cc5133d7abe7″ hover_enabled=”0″ sticky_enabled=”0″ title=”All-On-X Dental Implants – Pre-Consult Survey” success_message=”Complete! Our team will discuss your survey with you in your appointment.” submit_button_text=”Submit” email=”t.power@norlanedental.com.au,tc@norlanedental.com.au” custom_message=”A patient has submitted a response to the AOX Dental Implants Pre-Consult Survey.||et_pb_line_break_holder||||et_pb_line_break_holder||Patient Name: %%Patient_Name%%||et_pb_line_break_holder||Date of Birth: %%Date_of_Birth%%||et_pb_line_break_holder||||et_pb_line_break_holder||1. Main Goals:||et_pb_line_break_holder||%%main_goals%%||et_pb_line_break_holder||Other (if provided): %%Other1%%||et_pb_line_break_holder||||et_pb_line_break_holder||2. Treatment Option:||et_pb_line_break_holder||%%treatment_options%%||et_pb_line_break_holder||||et_pb_line_break_holder||3. Funding Preference:||et_pb_line_break_holder||%%funding%%||et_pb_line_break_holder||||et_pb_line_break_holder||4. Current Dental Situation:||et_pb_line_break_holder||%%dental_situation%%||et_pb_line_break_holder||Other (if provided): %%Other_2%%||et_pb_line_break_holder||||et_pb_line_break_holder||— End of submission —“][et_pb_contact_field field_id=”Patient_Name” field_title=”Patient Name” _builder_version=”4.24.0″ hover_enabled=”0″ global_colors_info=”{}” button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off” sticky_enabled=”0″ required_mark=”off”][/et_pb_contact_field][et_pb_contact_field field_id=”Date_of_Birth” field_title=”Date of Birth” _builder_version=”4.24.0″ hover_enabled=”0″ global_colors_info=”{}” button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off” sticky_enabled=”0″ required_mark=”off”][/et_pb_contact_field][et_pb_contact_field field_id=”main_goals” field_title=”1.⁠ ⁠What are your main goals for improving your smile or oral health?” field_type=”checkbox” fullwidth_field=”on” _builder_version=”4.24.0″ hover_enabled=”0″ global_colors_info=”{}” button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off” sticky_enabled=”0″ checkbox_options=”%91{%22value%22:%22Restore missing or broken teeth%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Improve comfort or reduce pain%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Enhance confidence and appearance%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%22Other%22,%22checked%22:0,%22dragID%22:2,%22link_url%22:%22%22,%22link_text%22:%22%22}%93″ required_mark=”off”][/et_pb_contact_field][et_pb_contact_field fullwidth_field=”on” _builder_version=”4.24.0″ _module_preset=”default” field_id=”Other1″ field_title=”Other:” hover_enabled=”0″ sticky_enabled=”0″ conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22main_goals%22,%22condition%22:%22is%22,%22value%22:%22Other%22}%93″ required_mark=”off”][/et_pb_contact_field][et_pb_contact_field field_id=”treatment_options” field_title=”2.⁠ ⁠Which treatment option are you most interested in learning about?” field_type=”checkbox” fullwidth_field=”on” _builder_version=”4.24.0″ hover_enabled=”0″ global_colors_info=”{}” button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off” sticky_enabled=”0″ checkbox_options=”%91{%22value%22:%22Fixed Full-Mouth Solution ($25,000 – $32,000 per jaw)%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Non-Fixed Full-Mouth Solution ($8,000 – $15,000 per jaw)%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Unsure – would like to discuss options%22,%22checked%22:0,%22dragID%22:1}%93″][/et_pb_contact_field][et_pb_contact_field fullwidth_field=”on” _builder_version=”4.24.0″ _module_preset=”default” field_id=”funding” field_title=”3.⁠ ⁠How do you plan to fund your treatment?” field_type=”checkbox” checkbox_options=”%91{%22value%22:%22Using Superannuation (own or partners)%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Payment plan / other finance option%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Not sure yet – would like more information.%22,%22checked%22:0,%22dragID%22:1}%93″ hover_enabled=”0″ sticky_enabled=”0″ required_mark=”off”][/et_pb_contact_field][et_pb_contact_field fullwidth_field=”on” _builder_version=”4.24.0″ _module_preset=”default” field_id=”dental_situation” field_title=”4.⁠ ⁠How would you describe your current dental situation?” field_type=”checkbox” checkbox_options=”%91{%22value%22:%22Missing or broken teeth%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Ongoing pain or sensitivity%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Difficulty chewing or smiling confidently%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%22Fear or anxiety about dental visits%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%22Other%22,%22checked%22:0,%22dragID%22:3}%93″ hover_enabled=”0″ sticky_enabled=”0″ required_mark=”off”][/et_pb_contact_field][et_pb_contact_field fullwidth_field=”on” _builder_version=”4.24.0″ _module_preset=”default” field_id=”Other_2″ field_title=”Other:” hover_enabled=”0″ sticky_enabled=”0″ conditional_logic=”on” conditional_logic_rules=”%91{%22field%22:%22dental_situation%22,%22condition%22:%22is%22,%22value%22:%22Other%22}%93″ required_mark=”off”][/et_pb_contact_field][/et_pb_contact_form][/et_pb_column][/et_pb_row][/et_pb_section]