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Dental Implants
In order to provide you a virtual consultation and assess your dental concerns, please submit your information below.
Your information will be securely sent back to our team to evaluate.
1. Do you have gaps or spaces between your teeth?
2. Do you have retained primary teeth or teeth that have been missing since birth?
3. Have you lost one or more teeth?
4. Are you dissatisfied with the condition of your teeth?
5. Do you experience discomfort or inconvenience due to removable partials or dentures?
6. If you wear removable dentures, do you find that you have a tendency to gag?
7. Are you embarrassed by the appearance of your teeth when you smile?
8. Are you dissatisfied with your ability to eat?
9. Do you suffer from pain related to your teeth?
10. Do you overcook foods to facilitate chewing?
11. Do you have teeth that appear to be loosening?
12. Do you feel that tooth loss has affected your:
13. Given the opportunity, what would you improve about your speech, appearance, comfort, chewing, or taste?
Smile & Profile
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Overbite & Overjet
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Upper Arch & Lower Arch
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Right Bite & Left Bite
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First Name
Last Name
Date Of Birth
Phone
Email
Preferred Contact Method
Preferred Contact Time
Notes, Comments, or Questions
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