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Questionnaire For Implant Patients Only
Questionnaire for Implants patients only
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* Indicates required question
Email
*
Your email
How many teeth are you missing?
1
2
3
More than 3
Clear selection
Have you consulted a Dentist regarding your oral health?
Yes, recently
Yes, some time age
No
Clear selection
Have you been told you need to have your teeth extracted?
Yes
No
Other:
Clear selection
Have you used dentures, a flipper, or bridge prior to implants?
Yes
No
Other:
Clear selection
Have you been told that you are not an ideal candidate for dental implants in the past?
Yes
No
Other:
Clear selection
What bothers you the most about your present oral condition?
Your answer
What has prevented you from getting dental treatment in the past?
Cost
Financial Issues
Fear of the Dentist
Schedule
Not aware of options
Other:
Clear selection
Do you have Dental Insurance?
Yes
No
Other:
Clear selection
Are you aware of the average fees for dental implants procedures ?
Yes
No
Other:
Clear selection
If you are interested in financing your treatment, which of the following options would suit you?
3rd Party No Interest Financing (generally 700+ credit score)
Partial Finance and Self-Pay
3rd Party extended term financing (generally 700+ credit score)
Cash, Personal Savings
Credit Card
Other:
How would you rate your credit?
*
Good 720+
Fair 640+
Poor -640
Not Sure
Other:
Required
Name
Your answer
Phone Number
Your answer
How did you hear about Dr.Chaudhry & Associates office
Internet Search
Radio
Television
Print
Friend, Family Member, or Colleague
Other:
Submit
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