Disclaimer: Before completing the Smile Assessment, please note that our office is located in Naples, FL. If you are not willing to travel to our office or if we are outside your range, please do not proceed with the assessment.

Would you like to proceed to completing the Smile Assessment for our Naples, Florida office? *

Yes

What is the primary reason you're seeking for dental implants? *

I'm Ready To Fix My Smile and Want To Know About Pricing

I have pain and discomfort

I'm coming for a second consultation

I've heard a lot about Dr. Evgeny Titov and I'd like to move forward with working him.

2. Which Condition Best Describes You? *

Missing One Tooth

Missing Multiple Teeth

Struggling With Traditional Dentures

Most Of My Teeth Are In Bad Shape

3. How Long Have You Been Missing Your Teeth? *

I Still Have My Teeth

1-6 Months

6 Months To 1 Year

1-5 Years

5+ Years

4. Are You Currently Experiencing A Lack Of Confidence In Social Situations Or Find Yourself Trying To Hide Your Smile? *

Yes

5. Are You Currently Trying To Find Relief From Any Kind Of Pain Or Discomfort? *

Yes

6. How bad is your pain and discomfort? *

Mild

Moderate

Severe

7. How Ready Do You Feel To Do Something About Your Situation? *

Somewhat Ready

Very Ready

I Need Something Fast!

8. We understand that going through a process like this can be quite taxing on a patient. Please allow us to understand what would potentially stand in the way of fixing your smile? *

Anxiety

Time or Length of Treatment

Financial Concerns

Distance to Office

Not Understanding Treatment Process

Embarrassment

Trusting The Provider

9. Most of our patients pay cash for the treatment. However, some do use our special financing program. Will you be using our special financing program for the treatment? *

Yes

10. Payment plans are available based on credit approval of the patient or a co-signer. Which best describes your credit? *

Excellent (720+)

Good (680-720)

Fair (620-680)

Below Fair (600-620)

Poor (Below 599)

First Name *

Last Name *

Date of birth *

Phone *

Email *

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Postal code *

When is the best time to contact you? *

Morning (9-12 Am)
Afternoon (12-5 PM)
Evening (5-8 PM)
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