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How Many Missing Or Broken Teeth Do You Have? *

All

4-5

3 Or Less

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What Is Your Age? *

60+

50-59

40-49

<40

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Do you currently have any of these dental solutions? *

Denture or Partial Denture

Bridge, Crown

Dental Implant

None of the above

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How Long Have You Been Missing Your Teeth? (The longer teeth are missing the more the jaw bone shrinks) *

I Still Have Them

1-6 Months

7-12 Months

1+ Years

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Are You Currently Unable To Eat Certain Foods Or Have To Modify The Way You Chew? *

Yes

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Are You Currently Trying To Find Relief From Any Kind Of Pain Or Discomfort? *

Yes

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Are You Currently Experiencing A Lack Of Confidence In Social Situations or Find Yourself Hiding Your Smile? *

Yes

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Have You Had A Dental Implant Consultation With Another Dentist? *

Yes

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How Ready Do You Feel To Do Something About Your Situation? *

Somewhat Ready

Very Ready

I Need Something FAST!

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Dental Implant procedures are not covered by insurance. However, many affordable payment plans are available. Are you interested in a payment plan option? *

Yes. I'm interested in affordable payment plan options

No. I've been saving for this type of procedure and will not need a payment plan

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National averages for dental implant procedures can range from $22,000 to $55,000. Payment plans start at $300/mo. Would you like to see if you qualify for payment plans, or still continue without? *

Yes, please tell me if I might qualify for a payment plan

No, I don't need a payment plan

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

(Poor) Under 660

(Fair) 660-699

(Good) 700-739

(Excellent) 740+

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Which best describes your current household monthly income? *

Under $5,000

$5,000 to $8,000

Over $8,000

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When is the best time to contact you? *

Morning

Afternoon

Evening

Almost Finished. Where can we send your results?

Full Name *

Email *

Phone *

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