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
Do You Currently Have Any Of The Following Treatments?
*
Crowns and/or Bridges
Partials
Dentures
None of the Above
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
Please Describe your current Oral Health situation and the challenges that you are Experiencing.
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
What Is your Level of Urgency To Find Relief From Any Type Of Pain Or Discomfort That You May Be Feeling?
1 - Very Little, I'm Not In A Rush
2- Moderate, I-3 Months
3 - High, I'm Looking For 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
Implant Supported Denture
Single Implant
Traditional Denture
Not Sure
Are You The Decision Maker In Regards To Your Dental & Healthcare?
Yes
No
Which Location Is Most Convenient For You?
Fond Du Lac, WI
Plymouth, WI
West Bend, WI
Beaver Dam, WI
Are you willing to travel to one of our other locations?
Yes
No
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
For your convenience, we will send you the customized information in regards to pricing for dental implants via text and email
Yes send me the information
No, I do not wish to receive information regarding pricing for dental implants
First Name
*
Last Name
*
Phone
*
Email
*
Postal code
*