All-on-X - Brush Dental Studio

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number* This field is required.
Please enter a valid phone number.
4
Preferred contact method* This field is required.
Phone
Email
5
What best describes your primary dental concern? (Select all that apply)
Missing one or more teeth
Missing most or all teeth in an arch (upper, lower, or both)
Loose or uncomfortable dentures
Failing dental work (e.g., crumbling crowns, failing bridges)
Deteriorating bone in my jaw
Other (Please specify briefly)
6
Other, please cpecify briefly
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Large
Normal
Small
Ok
Ok
7
How many teeth are you looking to replace?
One
A few (2-5)
Many (more than 5)
All teeth in my upper jaw
All teeth in my lower jaw
All teeth in both jaws
8
Are you currently wearing dentures or partials?
Yes, full dentures (upper, lower, or both)
Yes, partial dentures
No
9
Have you experienced any of the following? (Select all that apply)
Difficulty chewing certain foods
Speech difficulties due to missing teeth or dentures
Self-consciousness about your smile
Jaw pain or discomfort
Gum disease or infection
10
Are you generally in good health?
Yes
No (If no, please briefly explain any major medical conditions)
11
No (If no, please briefly explain any major medical conditions)
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Large
Normal
Small
Ok
Ok
12
Are you a smoker?
Yes
No
Used to be, but quit
13
What is your main goal for improving your smile and oral health? (Select all that apply)
Improve appearance/aesthetics
Restore chewing function
Increase comfort
Long-term solution/durability
Eliminate dentures
Boost confidence
14
What, if any, are your main concerns or barriers regarding dental implant treatment? (Select all that apply)
Cost/Financial considerations
Fear of dental procedures/Anxiety
Length of treatment / Time commitment
Uncertainty about the process
Unsure if I'm a good candidate
Potential pain or discomfort
None, just looking for information
15
When are you hoping to start treatment?
As soon as possible
Within the next 1-3 months
Within the next 3-6 months
Just exploring options for now
16
We offer flexible payment options at Brush Dental Studio. Are you interested in learning more about financing options for dental implant treatment?
Yes
No
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