Implant Survey

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

Are You Currently Wearing Dentures? *

Yes - Full Dentures

Yes - Partial Dentures

No

How Long Have You Been Missing Your Teeth?

I'm Not Missing Teeth

Less Than A Year

More Than A Year

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

Have You Seen Another Dentist About Dental Implants? *

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

What Is Your Primary Issue With Your Smile Right Now? *

Tooth Pain

Missing Teeth

Insecurities about the way you look

All of the above

What Is The Most Important Factor That Has Stopped You From Getting Treatment Previously? *

Time

Money

Fear

Can't Find The Right Dentist

Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods? *

Yes

No

Implants Are Capable Of Changing Lives - What Is Your Most Desired Outcome In A Full Mouth Rehabilitation? *

Function - Eating, Chewing, Talking

Aesthetics - Beautiful, Natural Looking Teeth

Both Are Equally As Important

How Fast Are You Looking To Change The Way You Smile? *

Very little, I'm in no rush

Moderate, Within 1-3 months

High, I need help now

Are You Familiar With An "All On 4" Treatment? *

Yes

No

Are You Interested In Learning About Financing Options?

Yes

No

Which option most closely represents your credit score? *

500 - 550

551 - 600

601 - 650

651 - 700

701+

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

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

Yes I consent to receive this information

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

Is There Anything Else You Would Like Us to Know About Your Dental Needs or Concerns? *

Our Practice Is Located In . Are You Willing To Travel To This Location? *

Yes

No

First Name *

Last Name *

Postal Code *

Phone *

Email *

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BC/BS Survey

Do you have a valid Blue Cross / Blue Shield PPO Medical Plan? *

Yes

No

Are you the subscriber or a covered dependent on this plan? *

Subscriber

Covered Dependent

Is your medical plan through your employer? *

Yes

No

Do you anticipate any changes to your medical insurance in the next 3-6 months? *

Yes

No

Do you have Medicare Part A or Part B? *

Part A

Part B

No, I do not have Medicare

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

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

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

Yes I consent to receive this information

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

Our Practice Is Located In . Are You Willing To Travel To This Location? *

Yes

No

Is There Anything Else You Would Like Us to Know About Your Dental Needs or Concerns? *

First Name *

Last Name *

Postal Code *

Phone *

Email *

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Implant Consult Form

First Name *

Last Name *

Phone *

Email *

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

Preferred Method of Communication *

Text

Phone

Email

Best Day for a Consultation *

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

I Consent to Receive SMS communication in regards to my scheduled consultation.