Treatment Enquiry Form

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Treatment Enquiry Form

Treatment Enquiry Form

Hi there, please fill out and submit this form if you're considering having treatment with us

1
Tell us what is bothering you* This field is required.
Just ONE tooth
More than one tooth
ALL of my teeth
An existing implant
A missing tooth or teeth
2
Where is the troublesome tooth situated?* This field is required.
At the FRONT of my mouth
About HALFWAY BACK in my mouth
At the BACK of my mouth
3
What seems to be the problem?* This field is required.
4
Are your problem teeth next to each other? * This field is required.
YESNO
5
Where are your troublesome teeth situated?* This field is required.
At the FRONT of my mouth
About HALFWAY BACK in my mouth
At the BACK of my mouth
6
Where in your mouth are these troublesome teeth?* This field is required.
7
What seems to be the problem?* This field is required.
There is pain around my implant
My implant is loose
My crown is loose
8
Sadly, problems with existing implants is something we see and hear frequently. It's important to understand the underlying cause to determine the correct treatment.
9
What would be your ideal outcome?* This field is required.
10
Are you currently wearing dentures?* This field is required.
Yes, TOP and BOTTOM
Yes, BOTTOM only
Yes, TOP only
No
11
What bothers you most about wearing your denture?* This field is required.
It's uncomfortable
It's loose
I'm embarrassed
I struggle to eat with it
All of the above
12
People who have never had dentures can't appreciate how tedious the constant niggle can be...
13
What is your ideal result...* This field is required.
I just want to secure my denture more firmly
I want to get rid of my denture completely
14
Even if only slighly loose, you worry about your denture falling out - inevitably at the worst possible moment.
15
What is your ideal result...* This field is required.
I just want to secure my denture more firmly
I want to get rid of my denture completely
16
It's easy to think that everyone's looking at your denture... even when they're not!
17
What is your ideal result...* This field is required.
I just want to secure my denture more firmly
I want to get rid of my denture completely
18
Being able to venture out of 'safe food' country again is something you only dream about.
19
What is your ideal result...* This field is required.
I just want to secure my denture more firmly
I want to get rid of my denture completely
20
Let's face it, problem dentures can be a real pain in so many different ways.
21
What is your ideal result...* This field is required.
I just want to secure my denture more firmly
I want to get rid of my denture completely
22
Where are your missing tooth/teeth located?* This field is required.
23
Do you currently wear a replacement denture?* This field is required.
YESNO
24
What would be your ideal outcome?* This field is required.
25
Okay great! We are confident we can help you.

We need some details and one of our implant experts will be in contact to answer your questions
26
Thanks, what email address shall we use?* This field is required.
example@example.com
27
May we have your name please?* This field is required.
First Name
Last Name
28
And the best phone number to contact you?* This field is required.
Please enter a valid phone number.
29
Which practice would you prefer to visit?* This field is required.
Hove
Haywards Heath
30
That's great!

Please press "SUBMIT" and we'll be in touch shortly!
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