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Dental Implants
When are you available for procedure?
Procedure
Dental Implants
Date from
Date to
What most concerns you about your current oral condition?
Smile
Chewing
Tooth problems
Ill-fitting dentures
Taste and eating difficulties
Lack of confidence
Other
Nothing, my oral conditions doesn’t bother me
How many teeth are you missing?
0
1
2
3 and more
I don’t know / I don’t remember
How long have you been missing your teeth?
Less than 6 months
More than 6 months
I don’t know / I don’t remember
Not applicable (I don’t have a missing tooth)
How did your oral problem occur?
Tooth Decay (Cavities)
Gum Disease (Periodontal Disease)
Trauma or injury
Medical Conditions (eg.diabetes)
Genetics or/and aging
Lack of regular dental checkup
Other
I don’t know /I don’t remember
I don’t have any dental problems
0%
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