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

How Long Have You Been Missing Your Teeth? *

I'm Not Missing Teeth

Less Than A Year

More Than A Year

Are you currently wearing dentures? *

Yes

What made you reach out to our office? *

Tooth Pain

Missing Teeth

Insecurities about the way you look

All of the above

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

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

Please Describe your current Oral Health situation and the challenges that you are Experiencing. *

What is your timeline to receive treatment? *

Very little, I'm in no rush

Moderate, Within 1-3 months

High, I need help now

Have you seen another dentist about your condition? *

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

Single Implant

Traditional Denture

Not Sure

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

Yes

Did You Know That Dental Implants Are Covered By Your Super Account? *

Yes

We offer many options to make Dental Implants affordable to our patients. Which of the following financing options would you be interested in? *

Super

Third party financing

Upfront payment

Other

If other fill in the blank

How Familiar are you with the "All-On-4" treatment? Scale of 1-10 *

First Name *

Last Name *

Phone *

Email *

Postal Code *

When is the best time to reach you for a quick chat to discuss your goals? *

Morning

Midday

Afternoon