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 - Full Dentures

Yes - Partial Dentures

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 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

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 Prevented You From Getting Treatment? *

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 The Term "All-On-4"? *

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 in terms of your options and timeline. *

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

What Location Is Most Convenient For You? *

• Charlottesville, VA
• Waynesboro, VA
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Is There Anything Else You Would Like Us to Know About Your Dental Needs or Concerns? *

First Name *

Last Name *

Postal code *

Phone *

Email *

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