CCOFS - Dental Implant Quiz Form

Are you currently missing any teeth?*

Not missing teethMissing 1-3 teethMissing 4-6 teethMissing 6+ teethMissing all my teeth

How long have you been missing teeth?

Less than a year1-2 years3-5 years6-10 years11 years or more

Do you currently wear or have any of the following restorations in your mouth? (Multiple choice)

A removable partial denture or full dentureDental implant(s)Crown or bridge workNone of the above

What is your biggest motivator for moving forward with dental implants? (Multiple choice)

Improve my ability to eat and speakBoost confidenceRestore my smile from an injury or accidentAlleviate oral discomfort or painI want to invest in a long-term solution for my dental problemsAll of the above

What is your age range?

40-50 years old50-60 years old60+ years or olderUnder 40 years old

Have you ever had a dental implant consultation?

Yes, at with my regular dentistYes, at another oral surgery practiceNo

Are you interested in a payment option?

YesNo
*Dental implants aren’t always covered by insurance, but we offer affordable payment options

When are you wanting to start your treatment?

As soon as possibleSoon (in a few weeks)I'm flexible (in a few months)Not sure, I am still doing research

Contact Information

We’ll follow up with your results and answer any questions. Ready to move forward? Provide your information below and we'll contact you to schedule your consultation!
First Name**
Last Name**
Phone Number**
Email Address**
How do you prefer to be contacted?*
What is your office preference?**
If this is a medical emergency please call 911. By submitting this form, you agree to be contacted by phone, email or text and that any associated call may be recorded for quality and training purposes. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.
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