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? *

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. *

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? *

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.

Full Name *

Email *

Phone *