Schedule a Dental Implant Consultation with Dr. Egolum
Hello there, thank you for your interest in Dental Implants at Creekside Oral Surgery and Dental Implants. We can't wait to share with you how you can restore your smile back to life! We need you to fill out this short questionnaire so we can get to know your situation a little better, once this is done you would have reserved your spot and our team will contact you to book you in. If this sounds good, please complete the form!
We will need to contact you, is it okay if we reach you via sms/text messages?
Yes
No
First of all, please let us know which condition best describes you.
*
Missing 1 Tooth
Missing Multiple Teeth
Struggling with Traditional Dentures
Most of My Teeth are in Bad Shape
Do you currently have any of these dental solutions?
*
Denture or Partial Denture
Bridge, Crown
Dental Implant
None of the Above
How Long Have You Been Missing Your Teeth? (The longer teeth are missing the more the jaw bone shrinks).
*
I Still Have Them
1-6 Months
7-12 Months
1+ Years
6+ Years
Are You Currently Unable to Eat Certain Foods or Have to Modify The Way You Chew?
*
Yes
No
Are you Currently Trying To Find Relief From Any Kind of Pain or Discomfort?
*
Yes
No
Are You Currently Experiencing A Lack Of Confidence in Social Situations or Find Yourself Hiding Your Smile?
*
Yes
No
What's kept you from getting your smile fixed?
*
Nothing! I'm ready right now!
Cost of Dental Procedures
Fear of Dental Procedures
Time Involved with Dental Procedures
Haven't Found a Dentist I'm Comfortable With
Payment plans are available at Creekside Oral Surgery and Dental Implants, would you be likely to go for a payment plan option?
*
Yes, I'd rather a payment plan
No, I'd rather pay up-front
What range does your credit score fall into?
800-850 (Excellent)
740-799 (Very Good)
670-739 (Good)
580-669 (Fair)
300-579 (Poor)
How Ready Do You Feel To Do Something About Your Situation?
*
Somewhat Ready, just need more information
Very Ready
I Need Something Fast!
Our consultation carries a FEE depending on what your needs are, we also require a $50 booking deposit to block out the time slot, this will be applied towards your consult/xray fee on the day of your visit . *If you do not show up to your appointment without 48 hour notice, the $50 will be charged as a cancellation fee.
*
Yes, I understand
No, I don't understand
Thank you, now you just need to provide contact details to reserve your spot, what is your name?
*
First Name
Last Name
What is your email address?
*
example@example.com
What is your phone number? (Preferably a cellphone number.)
*
Please enter a valid phone number.
Submit
Should be Empty: