Dental Implant Questionnaire

Dental Implant Solutions

Whether you have only one missing tooth or you have been wearing dentures for many years, the answers you receive from this questionaire will help you feel more informed and confident about taking up implant treatment.

On completition of the survey your personal report will be emailed to you. Please fill in your details below:

1. Do you have any teeth that are loose and failing?

Yes No

2. Do you have teeth that are badly broken down?

Yes No

3. Have you ever been told you have gum / periodontal disease?

Yes No

4. Are you missing one or more teeth?

None 1 2 3 More than 3 All

On the upper or lower jaw, or both?

Upper jaw Lower jaw Both

5. Have you had a facial trauma or surgery, either through an accident or illness that has caused you to have major tooth and bone loss?

Yes No

6. Do you have a partial denture?

Yes No

On the upper or lower jaw, or both?

Upper jaw Lower jaw Both

7. Do you wear a full removable denture?

Yes No

On the upper or lower jaw, or both?

Upper jaw Lower jaw Both

8. Have you been told you are not a candidate for dental implants due to lack of bone?

Yes No

9. Do you currently have dental implants or implant restorations that are failing?

Yes No

10. Do you have concerns about how long implant treatment will take?

Yes No

11. Do you feel that tooth loss has affected your: (tick all that apply)

Social Life Enjoyment of Food and Food Choices Speech Health Appearance Professional Life Self Confidence

Thank you for completing the survey

Your Dental Implant Suitability Report

Thank you for completing the suitability questionnaire. One of our dedicated treatment coordinators will be in contact with you soon to answer any further questions you may have, and to help you arrange a consultation.

Book a Consultation

Please complete the booking form below:

We will endeavour to offer you a consultation with your requested preferences.

If you would like to upload a photo of your smile please do so here:

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Dental Implant Solutions

On completition of the survey your personal report will be emailed to you. Please fill in your details below:

1. Do you have any teeth that are loose and failing?

2. Do you have teeth that are badly broken down?

3. Have you ever been told you have gum / periodontal disease?

4. Are you missing one or more teeth?

On the upper or lower jaw, or both?

5. Have you had a facial trauma or surgery, either through an accident or illness that has caused you to have major tooth and bone loss?

6. Do you have a partial denture?

On the upper or lower jaw, or both?

7. Do you wear a full removable denture?

On the upper or lower jaw, or both?

8. Have you been told you are not a candidate for dental implants due to lack of bone?

9. Do you currently have dental implants or implant restorations that are failing?

10. Do you have concerns about how long implant treatment will take?

11. Do you feel that tooth loss has affected your: (tick all that apply)

Thank you for completing the survey

Your Dental Implant Suitability Report

Book a Consultation

Please complete the booking form below:

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