What Best Describes Your Condition?
*
I Have All My Teeth
I'm Missing One Tooth
I'm Missing Multiple Teeth
I'm Missing All My Teeth
Are You Currently Wearing Dentures?
*
Yes
No
How Long Have You Been Missing Your Teeth?
I'm Not Missing Teeth
Less Than A Year
More Than A Year
Select All That Apply - Do You Feel That Tooth Loss Has Affected Your:
*
Personal Life
Professional Life
Enjoyment of Food
Physical Comfort
Oral Health
Appearance/Self Confidence
Have You Seen Another Dentist About Dental Implants?
*
No, This is 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
Implant Supported Denture
Single Implant
Traditional Denture
Not Sure
What Is Your Primary Issue With Your Smile Right Now?
*
Tooth Pain
Missing Teeth
Insecurities about the way you look
All of the above
What Is The Most Important Factor That Has Stopped You From Getting Treatment Previously?
*
Time
Money
Fear
Can't Find The Right Dentist
Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods?
*
Yes
No
Implants Are Capable Of Changing Lives - What Is Your Most Desired Outcome In A Full Mouth Rehabilitation?
*
Function - Eating, Chewing, Talking
Aesthetics - Beautiful, Natural Looking Teeth
Both Are Equally As Important
How Fast Are You Looking To Change The Way You Smile?
*
Very little, I'm in no rush
Moderate, Within 1-3 months
High, I need help now
Are You Familiar With An "All On 4" Treatment?
*
Yes
No
Are You Interested In Learning About Financing Options?
*
Yes
No
Which option most closely represents your credit score?
*
500 - 550
551 - 600
601 - 650
651 - 700
701+
For Your Convenience, We Will Send You The Customized Information In Regards To Pricing For Dental Implants Via Text And Email
*
Yes send me the information
No, I do not wish to receive information regarding pricing for dental implants
By Selecting No, We Have No Immediate Way To Send You The Information That You Are Requesting.
*
Yes I consent to receive this information
I would like to schedule an appointment to talk in person
I would like to speak to someone via phone call to discuss
I do not want this information
Our Practice Is Located In Commack, NY. Are You Willing To Travel To This Location?
*
Yes
No
Is There Anything Else You Would Like Us to Know About Your Dental Needs or Concerns?
*
First Name
*
Last Name
*
Postal Code
*
Phone
*
Email
*
Please check the box if you’d like to receive a call right away.