What Best Describes Your Condition? *

I Have All My Teeth

I'm Missing One Tooth

I'm Missing Multiple Teeth

I'm Missing All Teeth

How Long Have You Been Missing Your Teeth? *

I'm Not Missing Teeth

Less Than A Year

More Than A Year

Do You Currently Have Any Of The Following Treatments? *

Crowns and/or Bridges

Partials

Dentures

None of the Above

Have You Experienced Any Type Of Insecurities Regarding The Way Your Teeth Look? *

Yes

Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods? *

Yes

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 From Getting Treatment? *

Time

Money

Fear

Can't Find The Right Dentist

What Is Your Level of Urgency To Find Relief From Any Type Of Pain Or Discomfort That You May Be Feeling? *

Very Little, I'm Not In A Rush

Moderate, 1-3 Months

High, I'm Looking For Help Now

Have You Had Treatment Plans From Other Doctors For Dental Implants Recently? *

Yes

Are You The Decision Maker In Regards To Your Dental & Healthcare? *

Yes

Which Best Describes Your Current Credit Score? *

Below 580

580-699

700+

I'm Not Sure

How Are You Prepared To Pay For This Service? *

If cash, you will receive 10% discount off the overall treatment
If credit card, we accept AMEX, VISA, MASTERCARD, or DISCOVER
If financing, please fill out the APLHAEON CREDIT application once you submit this questionnaire
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First Name *

Last Name *

Phone *

Email *

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