Dream All-on-4® Quiz

1

Select (All) that apply

I don't like my smile

I can't eat

I'm in pain

I want my teeth pulled and implants placed

Other

3

Are you 21 years or older?* This field is required.

YESNO

4

Do you currently have

Dentures or partials

Crowns and bridges

Dental implants

None of the above

5

How long have you been missing your teeth?

I have all my teeth

1-6 months

7-12 months

1+ years

6

Are you the primary financial decision maker for dental or health care decisions?

YESNO

7

Are you currently unable to eat certain foods, or do you have to modify the way you chew?

YESNO

8

Are You Currently Trying To Find Relief From Any Kind Of Pain Or Discomfort?

YESNO

9

Have You Had A Dental Implant Consultation With Another Dentist?

YESNO

10

How Ready Do You Feel To Do Something About Your Situation?

Somewhat ready

Very ready

I need something fast

11

Dental Implant procedures are NOT predictably covered by insurance. However, many affordable payment plans are available. Are you interested in a payment plan option?

Yes and I have good credit

Yes and my credit is low

No, I have saved money for this

12

Payment plans are available based on credit approval of the patient or a co-signer. Which best describes your credit? (

*(Poor) Under 660

660-699

(Good) 700-739

740 or Above

13

Which best describes your current household monthly income?

Under $5,000

$5,000 to $8,000

Over $8,000

14

Have you watched Dr. Hendriks on youtube?

YESNO

15

What is your zip code?

16

What is your first name?

17

What is your last name?

18

What is your Email Address?* This field is required.

example@example.com

19

What is your Phone Number?* This field is required.

Area Code

Phone Number

20

Please take a photo (in good lighting) WITH your teeth TOGETHER and your UPPER lips pulled as HIGH as you can. This allows Dr. Hendriks to see if your a candidate. --> This photo is safe and will not be seen by anyone but Dr. Hendriks and Assistant.