First Name

Last Name

Phone *

Email *

What made you reach out to our office?

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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• List is empty.

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?

How long have you been missing your teeth?

• Less than a year
• More than a year
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• List is empty.

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)

Which location is most convenient for you?

Which location is most convenient for you?

• East Peoria, IL
• Moline, IL
• Davenport, IA
• Schaumburg, IL
• Chicago, IL
• Hammond, IN
• Lake Station, IN
• Portage, IN
• Murfreesboro, TN
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