Dental Implant Assessment
How many teeth are you currently missing?
All
6+
4-5+
3 or less
What is your age?
60+
50-59
40-49
<40
Do you currently have any of these dental solutions?
Dentures or partial dentures
Bridge or crown
Dental Implants
None of the above
How long have you been missing one or more of your teeth? (The longer teeth are missing the more the jaw bone shortens.)
I still have my teeth but need to have one or more removed
1-6 months
7-12 months
1+ years
6+ years
Which of the following are you experiencing:
Unable to eat certain foods
Have to modify the way you chew
Pain or discomfort
Lack confidence in social situations
Find yourself hiding your smile
All of the above
Have you had an implant consultation with another dentist?
Yes
No
Additional Information/comments:
We work with a number of financial lenders and many affordable payment plans exist. Are you interested in learning more about financing options?
Yes, I’m interested in learning about affordable payment plan options
No, I will not need a payment plan
Payment plan terms are available based on credit approval of the patient or a co-signer. Which best describes your credit?
N/A – I will not need financing
700+ (Excellent)
650-699 (Very Good)
601-649 (Good)
501-600 (Poor)
Under 500 (Very Poor)
I don’t know
How ready do you feel to do something about your dental situation?
I'm considering and just gathering information
Somewhat ready
Very ready
I need something FAST!
Name
First Name
Last Name
What is the best Email to reach you at?
example@example.com
What is the best Phone Number to reach you at?
Please enter a valid phone number.
Submit
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