kellermandental.com - Dental Implants Questionnaire Form

1

How many teeth are you missing?* This field is required.

A. None

B. One

C. Multiple

D. All

2

How long ago did you lose your teeth?* This field is required.

A. I’m not missing any teeth

B. Within the past year

C. Over a year ago

3

How urgently are you seeking relief from any discomfort?* This field is required.

A. Very urgent: I need immediate relief!

B. Somewhat urgent: The sooner I can get treatment the better

C. Not urgent: No rush, I can wait

4

Have you ever felt insecure about your smile?* This field is required.

Yes

No

5

Do you have difficulty chewing or eating some types of food?* This field is required.

Yes

No

6

Which of these is most important to you?* This field is required.

A. Function: Being able to eat and speak normally

B. Appearance: Having an attractive smile

C. Both are equally important

7

What’s your biggest barrier to seeking treatment?* This field is required.

A. Finances

B. Busy Schedule

C. Concerns about the treatment

D. Not knowing where to start

8

Which of these treatments have you had done?* This field is required.

A. Dentures

B. Crowns or bridges

C. Partial dentures

D. None of the above

9

Have you received a dental implant treatment plan from any other dentists recently?* This field is required.

Yes

No

10

Can you make final decisions about your health for yourself?* This field is required.

Yes

No

11

Select the option that is closest to your credit score.* This field is required.

A. Over 700

B. 580-699

C. Under 580

D. I don’t know

12

Your Name* This field is required.

First Name

Last Name

13

Phone Number* This field is required.

Please enter a valid phone number.

14

Email Address* This field is required.

example@example.com