What Best Describes Your Condition Currently? *

I Have All My Teeth

I'm Missing One Tooth

I'm Missing Multiple Teeth

I'm Missing All Of My Teeth

Are You Currently Wearing Dentures?

Yes

How Long Have You Been Missing Your Teeth? *

Less Than A Year

More Than A Year

You Feel As If Tooth Loss Has Affected Your: (Please Select All That Apply) *

Personal Life

Professional Life

Enjoyment of Food

Physical Comfort

Oral Health

Appearance/Self-Confidence

Have You Seen Another Dentist About Dental Implants *

No, This my first consultation

Yes, I did not feel comfortable with the other practice

Yes, I'm looking to compare pricing

If This Is A Second Opinion What Type Of Implant Solution Are You Looking For? *

Fixed Full Arch

Implanted Supported Denture

Single Implant

Traditional Denture

Unsure

What Factors Have Stopped You From Getting Treatment Previously? (Select All That Apply) *

Time

Money

Fear

Can't Find The Right Dentist

Implants Are Capable Of Changing Lives, What Is Your Most Desired Outcome Of Your Treatment? *

Function - Eating, Chewing, Biting

Aesthetics - Beautiful, Natural Looking Teeth

Both Are Equally As Important

How Quickly Are You Looking To Change The Way You Smile? *

Very quickly, I need help now

Moderately, within 1-3 Months

Very little, I'm in no rush

Which Option Most Closely Represents Your Credit Score? *

500-550

551-600

601-650

651-700

700+

Do You Want Additional Customized Information in Regards To Pricing For Dental Implants Via Text and Email? *

Yes

No, I do not wish to receive information regarding pricing for dental implants

Our Practice is Location in Denver, CO. Are You Willing to Travel to This Location? *

Yes

Is There Anything Else You Would Like Us To Know?

Phone *

Email *

Full Name

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