Call Today! 201-384-0100

29 West Church Street Bergenfield, NJ 07621

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Want A FREE Dental Implant Consultation?

What is the biggest problem that you’re having with your teeth right now? *

I’m missing 1-2 teeth

I’m missing more than 2 teeth

I want to get rid of my dentures

I need to have 1 or multiple teeth removed

If you have dentures, what issues do you have with them? (Select all that apply) *

My dentures fall out

My dentures are uncomfortable

I cannot eat the foods I like

I hate all the gunk I have to use to keep them in

I do not have dentures

How long have you been missing your teeth? *

I still have them

1-6 months

6 Months to 1 year

1 Year plus

Are you able to eat the foods you love with no discomfort? *

I have to limit the types of foods I can eat

It hurts when I chew

I chew mostly on one side of my mouth

I am able to eat comfortably with no issues

How are your teeth affecting your life? ( Select all that apply) *

I feel hopeless

I avoid social events

I can’t eat the foods I want

I avoid smiling

I hate taking pictures

I have lost confidence

None of the above applies to me

How soon do you want to get your teeth/smile fixed? *

As soon as possible

Within the next 3-6 months

In about a year

I’m still researching. I don’t know yet.

What’s kept you from getting your smile fixed? *

Nothing! I’m ready right now

Cost of dental procedures

Fear of dental procedures

Haven’t found a Dentist I’m comfortable with

PLEASE NOTE: Our office does not participate with Medicare or Medicaid Insurances.

What Dental Insurance Do You Have - other than Medicare or Medicaid? *

If payment plans were an option, is that something you would be interested in? *

Yes - I’m interested in a payment plan

No – I will not need a payment plan

Payment plans are available based upon credit approval of the patient or a co-signer. Which best describes your credit? *

(Very Poor) Under 500

(Poor) 501-600

(Good) 600-700

(Excellent) 700+

Based on your credit, you will most likely not be approved for dental implants. Do you have someone with good credit history who could co-sign with you? *

Yes

No

We do expect patients to respect our time and show up for their appointments. Do you commit to showing up for your appointment on time (once you’re scheduled)? *

Yes, I commit to showing up for my consultation on time

No, I cannot commit to showing up on time for my consultation

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Email *

Phone *

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Dr. Shahid • Top-Rated Dentist

in Bergenfield, NJ

Call Today! 201-384-0100

receptionist@bergenfielddental.com

29 West Church Street Bergenfield, NJ 07621

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