First Name
Last Name
Phone
*
Email
*
What made you reach out to our office?
Tooth Pain
Missing Teeth
Insecurities about the way you look
All of the above
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What would you like to change about your smile?
Have you experienced any type of insecurities regarding the way your teeth look?
Yes
No
Please describe your current oral health situation and the challenges that you are experiencing.
What is your timeline for starting treatment?
Very Little, I'm in no rush
Moderate, 1-3 months
High, I'm looking for help now!
Anything else that you would like for us to know regarding your smile?
Do you have any comments, questions, or concerns?
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
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
How long have you been missing your teeth?
Less than a year
More than a year
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Are you currently wearing dentures?
Yes
No
Does your current condition have a negative impact on your ability to eat or chew certain food?
Yes
No
What is the most important outcome you are seeking?
Function - Eating, Chewing, Talking
Aesthetics - Beautiful, Natural Looking Teeth
Both are Equally as Important
What are they most important factors that have prevented you from getting treatment?
Time
Money
Fear
Can't find the right dentist
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
Overdenture (Implant Supported Denture)
Single Implant
Traditional Denture
Not Sure
How familiar are you with the fixed full arch dental implant option on a scale of 1—10?
Do you currently have any of the following treatments?
Crowns and/or bridges
Partials
Dentures
Veneers
Clear Aligners
None of the above
Most dental implant procedures are not covered by insurance. However, we offer many payment plans that make it quite affordable and offer low monthly rates. Are you interested in a payment plan?
Yes, I am!
No, I will not need a payment plan.
Are you interested in financing options?
Yes, definitely!
Maybe, I would like to discover my options.
No, I am not interested in financing.
What dollar range would you be most comfortable with?
$150 - 249 per month
$250 - 349 per month
Over $350 per month
Payment plans are based on credit approval, you may also bring in a co-signer. If you could guess, what is your credit score?
500-550
551-600
601-650
651-700
701+
I don't know my credit score
What is the best time for a short discussion?
Morning (9am - 11am)
Noon (12pm - 1pm)
Afternoon (2pm - 4pm)
Best time for your consultation?
Morning (9am - 11am)
Afternoon (2pm - 4 pm)
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