It is important to answer the below questions honestly, to help ensure you are a candidate for dental implants.
How many teeth are you missing? —Please choose an option—1234567891011121314151617181920ALL
How many teeth would you like to have replaced with dental implants? —Please choose an option—1234567891011121314151617181920ALL
Approximately, when did you lose the teeth/tooth you’re considering having replaced by dental implants? —Please choose an option—Less than 1 Year1 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years11 Years12 Years13 Years14 Years15 Years
Do you see a dentist regularly?YesNo
Approximately when was your last visit to the dentist? —Please choose an option—6 Months12 Months18 Months24 Months
Were you ever told you have gum disease?YesNo
Please select the options given below :
Diabetic YesNo
Taking bisphosphonates (alendronic acid or similar medications, usually for osteoarthritis/ osteoporosis/ cancer medication)? YesNo
Taking Rheumatoid arthritis medications (typically ending in the letters “mab”)? YesNo
Taking any antidepressants?YesNo
None of the above (fit and healthy) YesNo
Do you currently smoke, vape or chew any tobacco or nicotine supplements?YesNo
For how many years have you smoked?—Please choose an option—1 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years11 Years12 Years13 Years14 Years15 Years
Have you smoked in the past, and if so when did you quit?—Please choose an option—N/A (Not Applicable)1 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years11 Years12 Years13 Years14 Years15 Years
Do you want to spread the cost using our payment options? —Please choose an option—YesNoMaybe
