Am I A Candidate For Dental Implants?

Find out if you qualify in less than 2 mins.

This is a candidacy form for the Modern Dental Smiles Dental Implant Center. This form will cover the basic requirements of the Dental Implants procedure, and help us to determine if you are a candidate for full-arch dental implants.

Do you currently have 4 or more missing or failing teeth on either arch (upper of lower)?

Failing teeth are those that can't be saved due to decay and/or breakage *

Yes

No, I am looking to replace a few teeth

Yes, I am currently without any teeth (dentures)

How long have you been completely without any natural teeth?

Do you have a history of bone diseases?

Osteoporosis, Paget's Disease, osteomalacia, etc. *

Yes

If yes, what is the bone disease you've been diagnosed with?

What is the bone disease you've been diagnosed with?

How far along in researching full-arch dental implants are you?

I'm just getting started and am unfamiliar with the costs and process

I've been looking into dental implants online.

I've been to at least one consultation and am aware of the process.

I'm a veteran. This ain't my first rodeo.

What is your highest priority in permanently restoring your smile with dental implants?

Treat health complications related to dental condition

Cut out future spending in temporary dental treatments

Regain confidence when smiling, talking, and laughing

Treating bone resorption / maintaining facial structure

Eating and properly chewing/digesting the foods you enjoy

Based on your history and goals, we believe that Dental Implants can be the right fit to help you take back control of your dental health.

A brief consultation with our doctor can help you confirm your candidacy.

Full Name *

Email *

Best email address to reach you

If you would like a phone call to set up a complimentary consultation, please leave your phone number and our Patient Care Coordinator will contact you

Preferably a cell phone to receive text confirmation. *

What is the best time to reach you?

A real-life Dental Implant coordinator will call you between the hours you choose. We do not use automation, bots, or call centers.

Is there anything else you'd like us to know?

Feel free to leave a message with any information relevant to your case.