New Patient Smile Assessment- Lower Implant Supported Denture Special

1

Which Condition Best Describes You?* This field is required.

1) Missing One Tooth

2) Missing Multiple Teeth

3) Struggling With Traditional Dentures

4) Most Of My Teeth Are In Bad Shape

2

Do You Currently Have Any Of These Dental Solutions?* This field is required.

1) Denture Or Partial Denture

2) Dental Implants

3) Bridge Crown

4) None Of The Above

3

How Long Have You Been Missing Your Teeth? (The Longer Teeth Are Missing, The More The Jawbone Shrinks.)* This field is required.

1) I Still Have Them

2) 1-3 Months

3) 3-6 Months

4) 6 Months to 1 Year

5) 1-5 Years

4

Payment plans are available based on credit approval of the patient or a co-signer. Which best describes your credit?* This field is required.

1) Excellent (720+)

2) Good (680-720)

3) Fair (620-680)

4) Below Fair (600-620)

5) Poor (Below 599)

5

Full Name* This field is required.

First Name

Last Name

6

Email* This field is required.

example@example.com

7

Phone Number* This field is required.

8

When is the best time to contact you?* This field is required.

1) Morning (9-12 Am)

2) Afternoon (12-5 PM)

3) Evening (5-8 PM)