Dental Implant Form

Dental Implant Form

Think you're a good candidate for dental implants? Fill out our dental implant patient form so we can assess your specific needs and goals.

Implant Form

Name*
Email*
Phone*
What best describes your condition?*
How long have you been missing your teeth?*
Have you ever had any tooth replacements such as, dentures, dental implants, etc.*
- Yes
- No
Have you experienced any type of insecurities regarding the way your teeth look?*
- Yes
- No
Does your condition have a negative impact on your ability to eat or chew certain foods?*
- Yes
- No
What is the most important outcome you are seeking?*
What is the most important factor that has prevented you from getting treatment?*
What is your level of urgency to find relief from any type of pain or discomfort that you may be feeling?*
Have you had treatment plans from other doctors for dental implants recently?*
- Yes
- No
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Still not sure if implants are for you? Explore other teeth replacement options or keep learning about the wonders of implant dentistry.

See Other Teeth Replacement Options Learn More About Dental Implants

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Drew Family Dentistry office exterior

Drew Family Dentistry

2215 NW Shevlin Park Rd, Suite 110
Bend, OR 97703
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Hours

Monday: 8:00 a.m. - 5:00 p.m.
Tuesday: 8:00 a.m. - 5:00 p.m.
Wednesday: 8:00 a.m. - 5:00 p.m.
Thursday: 8:00 a.m. - 5:00 p.m.
Friday: 8:00 a.m. - 2:00 p.m.

Phone

Fax

(541) 279-2356