Newest Appt Form

1
How many teeth are you currently missing?* This field is required.
0
1
2-3
4+
2
Are you currently wearing a partial or complete denture?* This field is required.
Yes
No
3
Please select the implant option that interests you the most.* This field is required.
Full Upper arch of implants
Full Lower arch of implants
Full Upper and Lower arch of implants
Individual or Single implants
Uncertain, I would value the Doctor’s Guidance
4
How would you define your ideal smile?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
5
On a scale of 1 - 10, how much dental pain are you currently experiencing?* This field is required.
Please Select
Please Select
0 - No Pain
1
2
3
4
5 - Moderate Pain
6
7
8
9
10 - Extreme Pain
6
Are there any other details about your smile that you’d like our team to be informed about?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
7
What has prevented you from pursuing the smile you've always envisioned?* This field is required.
Financial priorities kept me from moving forward
With my schedule, I haven’t been able to commit time to treatment
Dental procedures make me anxious, so ive been hesitant to take the first step
Embarrassment has made me reluctant to seek treatment until now
I wasn’t aware that there were options to help me regain my smile
Other
8
Can you share where you are in your journey toward your new smile?* This field is required.
Fully prepared to start with treatment
Currently seeking the right office to start treatment
I still have questions regarding treatment
I’ve recently become aware of the treatment and would appreciate more information
9
Please note that most dental implant procedures are not typically covered by insurance and involve considerable financial investment. To assist you, we have established partnerships with financing providers to offer competitive monthly payment options. Would you like information on how we can help with financing?* This field is required.
YESNO
10
What monthly payment amount fits within your budget?Skip if you do not need a payment plan
11
Payment plans are based on credit approval. If you could guess, what is your credit score?* This field is required.(estimations are acceptable)
Under 500
501-600
601-649
650-699
700+
Unsure
I don't need a payment plan
12
Name* This field is required.
First Name
Last Name
13
Email* This field is required.
example@example.com
14
Phone Number* This field is required.
Please enter a valid phone number.
15
Please indicate your preferred contact time and whether you would like to be reached by phone or email.
Huge
Large
Normal
Small
Ok
Ok
16
Anything else we should know?
Huge
Large
Normal
Small
Ok
Ok
17
How did you hear about Graf Dental Surgery?
Social Media
Referral/Friend
Mailer
Billboard
Website
TV
Other
Should be Empty: