Implant Form | Smile Solutions HI

Section 1

First & Last Name

Email

Phone

City, Island, Zip Code

Best dates/times to reach you: (Please give 2 options - time windows)

Please pick the best day & time for our team to give you a call.

How long have you been considering dental implants?

1-3 months

3-6 months

6-12 months

More than 1 year

What has stopped you from moving forward until now? (Choose ALL that applies)

Section 2

How is your smile currently affecting your life? (Check ALL that apply)

If your smile were fully restored, what would that change for you?

If you selected an event above, what is the date of this event? (if selected no, please add N/A)

Section 3

Have you been told that you have bone loss?

Yes

No

Any major medical conditions?

Yes

No

If selected yes above, what are your medical conditions?

Are you on blood thinners?

Yes

No

Have you had a previous implant consultation? (with Dr. Tony Kim or another Dentist)

Yes

No

If answered yes above, what was your estimated investment range for implants?

Section 4

We offer customized solutions and flexible financing options. To help us guide you appropriately.

Are you open to monthly payment options if approved?

Yes

No

I am able to pay in full

I am not sure

What monthly investment range will feel comfortable with you?

$150-$300

$300-$500

$500-$1000

More than $1,000

Will you be the main decision maker for this treatment?

Yes

No

Dr. Kim specializes in advanced full-arch implant solutions designed for long-term function and premium results. These treatments are a significant health investment.

Are you prepared to explore solutions in the $20,000–$50,000+ range depending on your needs?

Select what applies

Yes, I understand

I will need financing options

I am unsure right now

Mahalo for providing this necessary information so we can serve you the best as our client. We look forward to welcoming you to the Smile Solutions 'Ohana - Dr. Tony Kim

808.949.4145

Book Your Appointment Today

but first we have some questions for you