First Name

Last Name

Phone *

Address *

Street Address *

City *

State *

Postal code

Email *

Gender *

Date of birth

How Did You Hear About Us? *

In your last dental consultation, what were you told about your situation—and what was the approximate cost you were quoted? *

This helps us get a general sense of your diagnosis and treatment needs.

Have you had any recent hospital visits or major medical issues in the last 6 months? *

Yes

This is how the program works! The doctor donates the surgery and implant screws to you by providing them for free while they pay tuition to learn how to do the procedure under the supervision of our experienced faculty. You would be responsible for covering the cost of the final teeth that go on top, like crowns, bridges, or dentures. Does that make sense—yes or no? *

Yes

Similar programs are clinical trials, dental grants, or "free implants for seniors". Portions of the treatment are free/covered, but there will still be an out of pocket cost.

Would you be open to a payment plan if treatment was a good fit for you? *

Yes

Typically, 90% of patients do some kind of financing to pay for their teeth. It depends on their credit or the credit of their co-signer. Usually, on a full mouth of implants insurance will not pay more that $1,500 toward the overall cost of the treatment.

Are you able to travel to our clinic in Glendale, AZ multiple times over the next few months for appointments and procedures? *

Yes

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