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How many teeth would you like to improve or replace for a healthier smile? *

All

4-5

3 Or Less

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Could you please share your age with us? *

60+

50-59

40-49

<40

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Are you currently struggling with 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 experienced missing teeth? *

I Still Have Them

1-6 Months

7-12 Months

1+ Years

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Are there any foods you're finding difficult to eat, or have you been changing the way you chew? *

Yes

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Are you currently seeking ways to alleviate any pain or discomfort you may be experiencing? *

Yes

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Do you ever feel like your confidence could use a boost in social settings, or do you find yourself holding back your smile? *

Yes

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Have you had the chance to discuss dental implant options with another dentist yet? *

Yes

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How prepared do you feel to take action toward improving your situation? *

Somewhat Ready

Very Ready

I Need Something FAST!

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While dental implant procedures may not be covered by insurance, there are often affordable payment plans available. Would you like more information on payment plan options? *

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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Are you comfortable with an investment of $25,000+ for your treatment? *

Yes, I am comfortable with this investment.

No, this is outside my budget.

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Payment plans are available based on the credit approval of the patient or a co-signer. How would you describe your credit situation? *

(Poor) Under 660

(Fair) 660-699

(Good) 700-739

(Excellent) 740+

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Based on your credit situation you may need a cosigner. Do you have anyone who can cosign for you? *

Yes

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Without a cosigner, do you have any other means/resources to help fund treatment? *

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Could you share which category best fits your current household monthly income? *

Under $5,000

$5,000 to $8,000

Over $8,000

Almost Finished. Where can we send your results?

Full Name *

Email *

Phone *

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