All of our appointments are held at our Holmen, WI location. Would you be open to traveling to this location for your appointments? Please note, if you select "no," we will not reach out to schedule an appointment. *

Yes, I am willing to travel

No, I am not willing to travel

Maybe, I need more information first

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

More than 10 years

Are you currently wearing dentures? *

Yes

No

What Led You to Contact Our Office? *

Tooth pain

Missing teeth

Concerns about appearance

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

Is Your Dental Condition Affecting Your Ability to Eat or Chew Certain Foods? *

Yes

No

What Is the Primary Outcome You Hope to Achieve? *

Function - Eating, Chewing, Talking

Aesthetics - Beautiful, Natural Looking Teeth

Both Are Equally As Important

What Would You Say Is the Main Factor Preventing You from Moving Forward with Treatment? *

Time

Money

Fear

Can't Find The Right Dentist

Please Describe Your Current Oral Health Situation and Any Challenges You Are Experiencing: *

What Is Your Preferred Timeline for Receiving Treatment? *

Minimal urgency, I’m in no rush

Moderate urgency, within 1-3 months

High, I need help now

Have You Had a Consultation with Another Dentist Regarding Your Condition? *

No, This is my first consultation

Yes, but I didn’t feel comfortable with the other practice

Yes, I am comparing options and pricing

If This Is a Second Opinion, What Type of Implant Solution Are You Seeking? *

Fixed Full Arch

Implant Supported Dentures

Traditional Dentures

Single Implant

Not Sure

Are You the Primary Decision-Maker Regarding Your Dental and Healthcare Needs? *

Yes

No

Some Financing Options Are Subject to Credit Approval. If You’re Comfortable Sharing, Could You Estimate Your Current Credit Score? *

500 - 550

551 - 600

601 - 650

651 - 700

701+

How Familiar Are You with the "All-On-4" Treatment Option? *

I’m not familiar with it

I’ve heard of it but don’t know much

I’ve researched it extensively and know quite a bit

What Is the Best Time for a Short Phone Call to Discuss Options and Results? *

AM – Between 8:00 AM and 12:00 PM

PM – Between 1:00 PM and 5:00 PM

Is it okay for us to reach out to you via text, email, or phone call to discuss your dental implant options? *

Yes

No

By Selecting No, We Have No Immediate Way To Send You The Information That You Are Requesting. *

Yes, please feel free to reach out.

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

First Name *

Last Name *

Postal Code *

Phone *

Email *

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