Dental Implant Questionnaire

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Dentistry for Life

1. Which best describes how you feel?

2. Which best describes your present situation?

3. Do you have a denture? If no, answer "not applicable" on #4.

4. My dentures:

5. Do you have any insurance coverage for dental implants?

6. Can you participate/contribute to a flexible spending account?

7. If everything works out, when would you like to start dental implant treatment?

8. How much research have you done?

9. The following apply to me:

10. Contact information