Surgery/Procedure Multi-Date Inquiry Form

Timing is Everything!

Leverage your personal Right Timing for the best odds of great results with fast healing.

Use this form for a customized quote for multiple Surgery or Procedure Dates.

Please fill out and click Submit. All information will remain completely CONFIDENTIAL. We will get back to you with your custom date quote as soon as possible.

 

  • General Date Info

    Please submit ALL info to receive a prompt date quote. Missing info will delay your quote. You'll submit your birth data and all your particulars and preferences after you place your order.

  • Get the answers you need

    ...to fill out this form completely BEFORE you submit.You may need to consult your your doctor's or dentist's office, or someone else. Please do not submit until you have answers for all relevant questions.

  • Your Contact Information

  • Be sure to fill out the specifics for each date needed below.
    Please enter a number from 1 to 6.
  • How soon do you need your date? Standard lead time is 6 weeks after receipt of your paid order. Expedited delivery is available with these additional charges: 2 week delivery = $225, 1 week delivery = $395. If your deadlines differ, note this in the Additional Info section for each date.

  • Date #1

  • Example: Tooth extraction
  • Be SURE you'll be 100% ready to take action on this date. Your chosen date could possibly be found on this exact date or very shortly after.
  • Last possible date for this action.

  • Date #2

  • Example: Dental Implant Post
  • 1. Be SURE you'll be 100% ready to take action on this date. 2. Be sure that you've allowed any required time needed AFTER Date #1. Your chosen date could possibly be found on this exact date or very shortly after.
  • Last possible date for this action.

  • Date #3

  • Example: Place crown over dental implant post
  • 1. Be SURE you'll be 100% ready to take action on this date. 2. Be sure that you've allowed any required time needed AFTER Date #2. Your chosen date could possibly be found on this exact date or very shortly after.
  • Last possible date for this action.

  • Date #4

  • 1. Be SURE you'll be 100% ready to take action on this date. 2. Be sure that you've allowed any required time needed AFTER Date #3. Your chosen date could possibly be found on this exact date or very shortly after.
  • Last possible date for this action.

  • Date #5

  • 1. Be SURE you'll be 100% ready to take action on this date. 2. Be sure that you've allowed any required time needed AFTER Date #4. Your chosen date could possibly be found on this exact date or very shortly after.
  • Last possible date for this action.

  • Date #6

  • 1. Be SURE you'll be 100% ready to take action on this date. 2. Be sure that you've allowed any required time needed AFTER Date #5. Your chosen date could possibly be found on this exact date or very shortly after.
  • Last possible date for this action.
  • Some situations require specific spacing between dates. Example: 3 business days required between date #1 and #4. Please make sure this info is accurate.

  • Additional Comments or Information

  • All Requested Info Completed?

    Please check that all info is complete before you click Submit.

  • More Info will be needed!

    IMPORTANT! AVOID DELAYS!! Your order confirmation email will have a link to a different info form. Helena needs this additional info to complete your project. Please gather all info and return the new form ASAP.