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

Missing Teeth

Cracked Teeth

Tooth Pain

Cosmetics

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.

14. Although the first appointment is complimentary, 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.