Smile Survey All-On-4
Questionnaire for All on 4 canidates & Overdenture
Email address *
Are you currently wearing dentures? *
Required
How long have you been in dentures, or suffered from your present oral condition? *
Required
How many remaining upper teeth do you have?
Have you received a treatment plan from another dentist or clinic? *
Required
Have you been told you need to have your teeth extracted?
Have you been told you are not candidate for Dental Implants?
What bothers you the most about your present oral condition?
How has your oral health impacted your life?
Your answer
What has prevented you from getting dental treatment? *
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
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?
Are you aware of the average fees for these procedures ?
If Dr. Chaudhry & Associates were able to alleviate your concerns, how soon would you begin treatment? *
Do you have Dental Insurance?
If you are interested in financing your treatment, which of the following options would suit you?
How would you rate your credit? *
Required
Name
Your answer
Phone Number
Your answer
How did you hear about Dr. Chaudhry & Associates office?
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