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 *