ADI Schedule

1

How can we help? Tell us about you.

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Tell us about your current dental condition

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*What Is Your Current Dental Condition?*
- Missing Teeth
- Cracked, Loose or Failing Teeth
- Periodontal Disease
- None of the Above
Select all that apply
*What Dental Solutions Do You Currently Have?*
- Denture or Partial Denture
- Bridge, Crown
- Dental Implant
- None of the Above
Select all that apply
Number of years wearing dentures, partial denture, flipper
Please enter a number greater than or equal to 1.
*What Do You Hope To Gain From Dental Implants?*
- Better Eating/Talking, Improve Health
- Feel More Confident
- Improve Smile/Appearance
- Repair Accident or Injury
- Suggested by Family/Friend
- Recommended by Dentist/Doctor
- None of the Above
Select up to 3 options
*Explain how dental implants would improve your life*
Accessibility
- I am hearing impaired and require a signing translator
To help accommodate you, please call 888-651-9950

3

Choose your appointment date/time

Make your appointment

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Agree to Terms*
- The individual is over the age of 18 and agrees to terms and conditions

Tell us about your current dental condition