Prescreening Questionnaire

1
Has your dentist told you that you need a tooth pulled/removed?
YESNO
2
Please provide the name and phone number of your dentist.
Dentist Name
Dentist's phone number
3
Please briefly explain why you believe you need an implant.
4

Find your tooth that needs to be replaced on the diagram. Is it white or grey? Remember the color and click next.
5
From the previous image, what color did your tooth match with?* This field is required.
WHITE
GREY
6
Is this tooth still in your mouth? It's okay if it's cracked or broken.* This field is required.
YESNO
7
Do you regularly use nicotine products like cigarettes, cigars, chewing tobacco or vapes?* This field is required.
YESNO
8
Are you between 22 and 80 years old?* This field is required.
YESNO
9
Do you have Type II Diabetes?* This field is required.
YESNO
10
Are you pregnant or are you currently trying to get pregnant?* This field is required.
YESNO
11
When is the last time you had a dental appointment?
Please Select
Please Select
Within the last 6 months
Within the last year
Within the last 2 years
More than 2 years ago
12
Subjects in this research study are required to complete 8 visits to the clinic (in Cambridge, MA) after receiving their implant over a 15-month time period. Will you commit to completing these visits?* This field is required.
YESNO
13
I agree to share the information provided in this form only with ADA Forsyth Institute for the sole purpose of reviewing my eligibility for the implant clinical study.* This field is required.ADA Forsyth Institute will not share this information with any third parties and will delete all your personal information on completion of the eligibility review.
YESNO
14
We're sorry, you are not elligible for this study.

If you know someone who needs a dental implant and may qualify, please share the link to this survey with them. Thank you.
15
Please provide the information requested on the remaining pages of this form and someone will be in contact with you soon.* This field is required.
First Name
Last Name
16
Email* This field is required.
example@example.com
17
Phone Number* This field is required.
Please enter a valid phone number.
18
Where do you live?* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
19
How did you find us?* This field is required.Please select where you found this questionnaire
Please Select
Please Select
Paper flyer in the Boston/Cambridge area
My Dentist told me about this
Facebook/Instagram Ad
iDentical Implant Website
Other
Should be Empty: