DENTAL IMPLANT SURVEY
ARE YOU A CANDIDATE FOR DENTAL IMPLANTS?
What best describes your condition?
I have all of my teeth.
I am missing one tooth.
I am missing a few teeth.
I am missing many teeth.
I am missing all of my teeth.
How long have you been living with tooth loss?
0-2 Years
2-5 Years
5-10 Years
Over 10 Years
What is the most important outcome you are seeking?
Function - eating, chewing, talking
Aesthetics - beautiful, natural-looking teeth
Both are equally as important
What is the most important factor that has prevented you form getting treatment?
Time
Fear
Money
Can't find the right dentist
What is your level of urgency to find a solution for your dental needs?
Very little, I'm not in a rush
Moderate, 1-3 months
High, I'm looking for help now!
Have you had a consultation or treatment plan from other dentists for dental implants?
Yes
No
Upon credit approval or with the help of a cosigner, payment plans are available. Which best describes your credit?
*
(Very Poor) Under 500
(Poor) 500-649
(Good) 650-749
(Excellent) 750+
I don't know
What is your preferred location?
Cherry Creek
Broomfield (Westminster)
Boulder
First Name
*
Last Name
*
Phone
*
Email
*
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