Implant form

1

How many teeth are you currently missing?

I have all my teeth

I'm missing one tooth

I'm missing multiple teeth

I'm missing all my teeth

2

Are you currently wearing partials or dentures?* This field is required.

YESNO

3

How long have you been missing teeth?

Less than one year

More than one year

I'm not missing teeth

4

What made you reach out to our office?

Tooth pain

Missing teeth

Insecure about the appearance of my teeth

All of the above

5

Does your condition have a negative impact on your ability to eat or chew certain foods?* This field is required.

YESNO

6

What is the most important outcome you are seeking?

Function - eating, chewing, talking

Esthetics - Beautiful Teeth

Both are equally important

7

What has prevented you from getting treatment?

Time

Money

Fear

Can't find the right dentist/office

8

What is your timeline to receive treatment?

Very little - I'm in no rush

Moderate - within 1-3 months

High - I need help now

9

Have you seen another dentist about your condition?

No, this is my first consultation

Yes, I did not feel comfortable with the other office

Yes, I'm looking to compare pricing

10

Please select the implant options that interest you the most.

Full arch of implants

Snap-In denture

Single/Individual implant

Traditional denture

Uncertain, I would value the Doctor's guidance

11

Most dental implant procedures are not covered by insurance but we offer multiple financing solutions that make it quite affordable and offer low monthly rates. Are you interested in a payment plan?* This field is required.

YESNO

12

Are you interested in learning about financing options? If so, what dollar range would you like to pay monthly?

No financing needed

$200-400/month

$400-600/month

$600-800/month

Over $800/month

13

How familiar are you with "All-on-4", "Teeth in a day" treatment? Scale 1-10* This field is required.

14

We will send you personalized information in regards to pricing for dental implants via text and email.

Yes, send me the information

No, I would prefer a call from an implant consultant

15

What specific information would you like to give our implant coordinator?

16

Contact Information

17

Our office is located in Puyallup, WA. Are you willing to travel to this location?* This field is required.

YESNO