Our practice is located in Holmen, WI. Are you willing to travel to this location? *

Yes

Please Describe your current Oral Health situation and the challenges that you are Experiencing. *

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

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

What Is the Primary Outcome You Hope to Achieve? *

Function - Eating, Chewing, Talking

Aesthetics - Beautiful, Natural Looking Teeth

Both Are Equally As Important

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

What Treatment Option Was Recommended?

What Was The Reason You Did Not Move Forward With Treatment At That Time? *

What Treatment Option Are You Interested In? *

Fixed Full Arch

Implant Supported Dentures

Traditional Dentures

Single Implant

Not Sure

What Has Prevented You From Exploring Treatment Options In The Past? *

What is your timeline to receive treatment? *

Minimal urgency, I’m in no rush

Moderate urgency, within 1-3 months

High, I need help now

Are You Interested In Learning About Financing Options? *

Yes

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+

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

Anything Else That You Would Like For Us to Know Regarding Your Smile? *

May we contact you via text, email, or phone to provide more information? *

Yes, please feel free to reach out.

No, I prefer not to be contacted.

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 *