Form cover
Page 1 of 1

Are You a Candidate for Dental Implants?

We appreciate you choosing us as your dentistry office. To better assist you, please fill answer the questions below!
The smile of your dreams is one click away!

1. What best describes your current dental situation?

1. What best describes your current dental situation?
A
B
C
D

2. How long have you been missing teeth?

2. How long have you been missing teeth?
A
B
C

3. Do you currently wear dentures?

3. Do you currently wear dentures?
A
B

4. What is your main reason for seeking dental implants?

4. What is your main reason for seeking dental implants?
A
B
C
D

5. Are you experiencing difficulty eating or chewing food due to missing teeth?

5. Are you experiencing difficulty eating or chewing food due to missing teeth?
A
B

6. What is your top priority when it comes to dental implants?

6. What is your top priority when it comes to dental implants?
A
B
C

7. Please describe any dental issues you are currently facing.

8. Have you already consulted another dentist about your condition?

8. Have you already consulted another dentist about your condition?
A
B
C

9. If you have already received a consultation, what type of implant solution are you considering?

9. If you have already received a consultation, what type of implant solution are you considering?
A
B
C
D
E

10. Do you have insurance?

10. Do you have insurance?
A
B

11. Are you interested in learning about our flexible payment plans? If so, how many months would you prefer for an interest-free payment option?

11. Are you interested in learning about our flexible payment plans? If so, how many months would you prefer for an interest-free payment option?
A
B
C
D

12. Would you like to receive more information about pricing and available appointment times via call, text, or email?

12. Would you like to receive more information about pricing and available appointment times via call, text, or email?
A
B