2. Are you able to eat comfortably?

I chew mostly on one side

I have pain when I chew

I limit the types of foods I can eat

I am able to eat comfortably

3. What are some of the things you would like to improve about your smile?

Missing Teeth - I need to replace my missing teeth.

Stained Or Unattractive Teeth - I want my teeth to look attractive.

Tooth Alignment - My teeth are not straight.

Nothing, I'm happy with my smile.

4. If this is your second consultation please explain why you would like a second opinion?

This is my first consult.

I did not feel confident in the doctor at the other practice.

I did not feel comfortable at the other practice.

I would like to compare prices.

5. Major dental implant treatment may require a substantial financial investment. Have you planned on how you will pay for the work needed?

I have good credit and would like financing arrangements.

I will pay out of pocket.

I do not have great credit and will need other financial assistance.

I have not given thought to this.

6. When it comes to your comfort at the dental office would you say you are:

A Nervous Patient

Relaxed At The Dentist

Sometimes Nervous, But Mostly Okay

7. Why are you taking this first step to correct your dental health?

I am in pain.

I have lost confidence in my smile.

I am unable to chew.

All of the above - I'm in pain, lack confidence, & cannot chew.

8. What is the most important to you when selecting a dental health provider?

Financing Options

Experience & Level Of Expertise

Flexibility Of Appointment Times

Price

9. What type of dental implant solution are you interested in?

Full Fixed Arch Implants - I want the best quality full mouth restoration possible, even if it's more expensive.

Implant Retained Dentures - I want an implant denture hybrid. I'm looking to balance quality with price.

Implant Bridge - I want to replace just a few missing teeth in a row.

Single Dental Implant - I'm missing one or two single teeth that need to be replaced.

10. How urgent is this treatment to you?

Patients without teeth lose as much as 25% of their bone width within the first year. The longer you wait to replace missing teeth, the more advanced your bone loss will become.

I want this done ASAP. I'm in pain / tired of feeling sick and I'm ready to improve the quality of my life.

I want this done 1-3 months from now. I definitely want this treatment, I just need a little more time.

I'm still researching, I don't know yet.

11. If you require financing, please select the option below that best describes your credit history.

Please tell us what category you are in - the better your credit score is the more likely you are to get approved for financing.

Poor Credit (Under 650)

Average Credit (650-700)

Good Credit (700-750)

Great Credit (750+)

12. If you are looking to finance your dental treatment, healthcare financing companies will ask for a source of income. Do you have a job / source of income?

Yes, I have a job/source of income.

No, I don't have a job/source of income.

13. Should you have difficulty getting approved for financing, do you have a co-signer to help you?

If you have a low credit score and need full mouth implants, you will need a Co-Signer.

Yes, I have a Co-Signer.

No, I don't have a Co-Signer.

Not Applicable - I have at least a 650 credit score, therefore I don't need a Co-Signer.

14. Although the first appointment is $1, we do expect new patients to respect our time and show up for their appointment. Do you commit to showing up for your appointment at the time it is scheduled?

Yes, I commit to showing up for my consultation on time.

No, I cannot commit to showing up on time for my consultation.

1. What is your main concern that has brought you to our office?