Vestal Dental Associates - Dental Implant Intake Questionnaire

Let's Get Started

Please provide your basic contact information so we can reach you.

First Name *

Last Name *

Email Address *

Phone Number *

Preferred Contact Method *

Phone

Email

Text Message

Your Current Dental Situation

Help us understand your tooth loss situation and needs.

How many teeth are you missing or need to be replaced? *

When did you lose your tooth/teeth? *

Are you currently experiencing any of these issues? (Select all that apply)

Difficulty chewing

Jaw pain or discomfort

Shifting of surrounding teeth

Self-consciousness about your smile

Speech difficulties

None of the above

Medical History

This information helps us provide the safest and most effective treatment for you.

Do you currently have any of the following conditions? (Select all that apply)

Uncontrolled diabetes

Active gum disease

Currently undergoing cancer treatment

Osteoporosis or taking bisphosphonates

Heavy smoker (more than 1 pack/day)

Blood clotting disorders

None of the above

Have you been told you have insufficient bone density in your jaw? *

Are you currently pregnant or nursing?

Good to know: Don't worry - many conditions can be managed with proper treatment planning. Our experienced team has successfully placed implants for patients with various health considerations since 1955.

Your Dental Experience

Understanding your previous experience helps us provide better care.

Have you had dental implants before? *

Have you consulted with another dentist about implants? *

How would you describe your comfort level with dental procedures? *

We're here for you: We offer sedation dentistry options and our team specializes in making nervous patients feel comfortable and at ease.

Your Goals & Priorities

Help us understand what matters most to you.

What are your primary goals for dental implants? (Select all that apply) *

Restore chewing function

Improve appearance/smile

Prevent further bone loss

Eliminate removable dentures

Long-term permanent solution

Protect remaining natural teeth

Rank your top 3 decision factors (1 = Most Important)

Experienced, qualified dental team

Advanced technology and techniques

Long-term success and durability

Natural appearance

Single-visit options when possible

Flexible financing options

Timeline & Expectations

Help us understand your timeline and readiness for treatment.

When are you hoping to begin treatment? *

Are you aware that the complete implant process typically takes 3-6 months? *

How did you hear about Vestal Dental Associates? *

Additional comments or questions?

You're Almost There!

Based on your responses, you appear to be a great candidate for dental implants. Here's what happens next:

What to Expect:

1

Free Consultation

Comprehensive examination with one of our experienced dentists

2

Advanced Digital Imaging

3D CBCT scan to assess bone structure and plan your treatment

3

Personalized Treatment Plan

Custom plan with clear timeline and transparent pricing

4

Discuss Your Options

Sedation options, financing, and all your questions answered

65+ Years Experience

Serving Greater Binghamton since 1955

Advanced Technology

CEREC, 3D imaging, laser dentistry

Yes, please send me appointment reminders via text message

Your information is secure and will never be shared

Dental Implant Candidacy Questionnaire

Let's Get Started

Your Current Dental Situation

Medical History

Your Dental Experience

Your Goals & Priorities

Timeline & Expectations

You're Almost There!

What to Expect:

Proudly Serving Patients in the Following Communities

About Us

Procedures

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