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 soon are you looking to move forward? *

As soon as possible

Within 1-3 months

Just researching for now

Do you have any of the following medical conditions? (This does not disqualify you — this information is important when creating your treatment plan.) *

Diabetes

Osteoporosis

Heart Condition

Autoimmune Disorder

None of the above

Would you need financing options to proceed? *

Yes

No

Possibly – want to learn more

This helps us guide you to the financing options most likely to work for you — this is not a credit check. *

700+ — Excellent Credit

650–700 — Good Credit

600–649 — Fair Credit

Below 600

Prefer not to say

For Your Convenience, We Will Send You The Customized Information In Regards To Options & Treatment Plan For Dental Implants Via Text And Email *

Yes send me the information

No, I do not wish to receive information 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 Spring Lake, MI. 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 *

City *

State *

Phone *

Email *

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