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Smile Survey All-On-4
Questionnaire for All on 4 canidates & Overdenture
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* Indicates required question
Email
*
Your email
Are you currently wearing dentures?
*
Yes
No
Other:
Required
How long have you been in dentures, or suffered from your present oral condition?
*
1-5 Years
5-10 Years
10-15 Years
15-20 Years
20 Years+
N/A
Other:
Required
How many remaining upper teeth do you have?
1-3
4-8
More than 8
Have you received a treatment plan from another dentist or clinic?
*
Yes
No
Required
Have you been told you need to have your teeth extracted?
Yes
No
Other:
Have you been told you are not candidate for Dental Implants?
Yes
No
Maybe
Clear selection
What bothers you the most about your present oral condition?
Smile
Chewing
Bad Teeth
Dentures don't fit
Ability taste food & eat food
Confidence
Other:
How has your oral health impacted your life?
Your answer
What has prevented you from getting dental treatment?
*
Cost
Financial Issues
Schedule
Fear of the Dentist
Healing Times
Expertise of the Dentist
Not aware of options
Other:
Required
How would you rate your concerns regarding treatment?
Cost of Treatment
Length of Treatment
Candidacy for treatment
Success rate of treatments
Expertise of the Dentist
If it's worth it
Very Important
Somewhat Important
Not Important
Cost of Treatment
Length of Treatment
Candidacy for treatment
Success rate of treatments
Expertise of the Dentist
If it's worth it
Very Important
Somewhat Important
Not Important
What Foods do you like eating that you currently can not eat ?
Your answer
Have you been researching All-On-Four procedures on the internet?
Yes
No
Clear selection
Are you aware of the average fees for these procedures ?
Yes
No
Other:
Clear selection
If Dr. Chaudhry & Associates were able to alleviate your concerns, how soon would you begin treatment?
*
Immediately
Next Week
Within 30 days
0-60 days
60 days+
Other:
Do you have Dental Insurance?
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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