Click on Calendar, type the year 'YYYY' and pick the month & date.
Dentistry At Its Finest
Print blank form to fill by hand

  Last name

  Mid Initial

  First name

Implant Dentistry Questionnaire

1. I’ve heard of “All on 4” and want to learn more? Yes No
2. Do you have a problem in teeth and DON’T WANT TO WEAR dentures? Yes No
3. Do you think your teeth are hopeless? Yes No
4. I have full dentures and hate them? Yes No
5. I’m tired of wasting money on dentistry that doesn’t last or make me happy? Yes No
6. Have you heard about “teeth in a day” and are interested in learning more? Yes No
7. I don’t want my husband or wife to see me without teeth? Yes No
8. I gag on my dentures? Yes No
9. I think I need dentures but I’m worried about gagging on them? Yes No
10. I’m missing one or a few teeth and want them replaced without drilling my excellent adjacent teeth for a bridge. Yes No
11. I’m wearing or can’t wear or hate my removable partial denture and want to find out about permanent replacement teeth? Yes No
12. My full lower denture moves when I chew and just want to find out if 2 implants can help secure them without getting into non-removable teeth? Yes No
13. My existing bridge replacing my one missing front tooth has dark lines along the gum line and its looks awful. Yes No
14. Has a dentist told you that you are not a candidate for dental implants? Yes No
15. Have you had a CT scan (3 dimensional x-ray) of your mouth to see if you are a candidate for dental implants? Yes No
16. What do you think the causes of your dental problems are?
Born with soft teeth
Poor dentistry
My own neglect
Diet causing cavities
Gum disease
Dentists in the past not caring
I wasn’t ready at the time to fix my mouth but I might be able to now
I never had the right dentist to help me
17. Is there anything you would like Dr. Matarazzo to know about yourself or dental problems?

(Your digital signature (full name) is as legally binding as a physical signature.)