SINGLE IMPLANT CANDIDATE ASSESSMENT

1
What Is Your Name?* This field is required.Please enter your name below.
First Name
Last Name
2
Date of Birth* This field is required.Example: December 25, 1962 would be entered 12/25/1962
Date
Month
Day
Year
3
Phone NumberExample: (843)554-1111
(XXX) XXX-XXXX
4
Have you ever had implant(s) placed before?* This field is required.
YESNO
5
How many implants do you currently have placed?* This field is required.
6
What best describes your teeth right now?* This field is required.Select One Answer
I am missing one tooth
I am missing several teeth
I am missing most of my teeth
Most of my remaining teeth are broken or loose
I wear a partial denture
I wear a full denture/plate
My teeth are mostly healthy
7
What are you hoping to accomplish with implants?* This field is required.Select Up to 3 Options
Replace one missing tooth
Replace several missing teeth
Stop wearing dentures
Replace my remaining teeth with implants
Improve my ability to chew
Improve my smile
I'm just researching options
Other
8
How would you rate your smile?* This field is required.Move the emoji to the left or the right
Rate Your Smile
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
Rate Your Smile
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
9
Have you been diagnosed with diabetes?* This field is required.
YESNO
10
What was your most recent A1C?* This field is required.
Below 7%
7.0 - 7.9%
8.0 - 8.9%
9% or higher
I don't know
11
Have you experienced any of the following?* This field is required.Select All That Apply
Heart Attack
Stroke
Heart Stent
Heart Failure
Other heart condition
None of these
Other
12
Have you ever been treated for cancer?* This field is required.
YESNO
13
What type of cancer treatment have you experienced?* This field is required.Select All That Apply
Chemotherapy
Radiation
Radiation to my head or neck
Cancer involving my bones
Currently receiving cancer treatment
I do not know the treatment
I have had cancer but received none of these treatments
14
Have you ever been diagnosed with any of the following?* This field is required.Select All That Apply
Osteoporosis
Bone Loss
Cancer involving the bones
None of these
15
Have you been prescribed any of the following medications?* This field is required.Select All That Apply
Fosamax
Prolia
Reclast
Zometa
Xgeva
No I have not
16
Has a licensed dentist ever told you that you don't have enough bone for implants?* This field is required.
YESNO
17
Did the licensed dentist express alternative options to implant treatment?* This field is required.
YESNO
18
If you're a candidate, when would you ideally like to begin treatment?* This field is required.Select One Answer Only
As soon as possible
Within 30 days
1 - 3 months
3 - 6 months
6 months or more
I'm only researching right now
19
Clinical Assessment Score
20
We believe patients should have clear pricing information before investing time in the consultation process. A single implant, abutment, and crown has a standard value of $5,250. Our package rates are $4,500 for one implant, $8,000 for two implants, or $10,500 for three implants. Package pricing is valid for 30 days following clinical approval. If you are determined to be a candidate, how would you plan to pay for treatment?* This field is required.Select One Answer Only
I plan to pay for treatment myself
A combination of cash and financing
I would need financing
A family member/spouse may assist
I need to learn about my options
This investment is outside my budget
21
Would you like someone from our office to contact you directly about your next steps?
YESNO
22
What would be the best way to contact you?Select All that Apply
Phone Call
Text Message
Email
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