Complete this short questionnaire to receive your

dental implant guide and dental implant consultation.

What is your age? *

60+

50-59

40-49

Under 40

How many teeth are you currently missing? *

One

Several

Most or all

Do you currently have any of these dental solutions? (Select all that apply) *

None

Dentures / partial

Bridge

Dental implant

Other

Are you currently unable to eat certain foods or have to modify the way you chew? *

Yes

Are you currently experiencing a lack of confidence in social situations or find yourself hiding your smile? *

Yes

Have you had a dental implant consultation with another dentist? *

Yes

How ready are you to move forward with a dental implant procedure? *

Ready now!

Within 3-6 months

Just gathering information

Implants are considered an elective procedure and are not covered by Medicare or Medicaid. Would you still like to explore your financing or payment options with us? *

Yes

Full mouth dental implants start at $12,995 per arch (per jaw), with financing options as low as $275/month (with approval). Does this sound like an investment you’d consider? *

Yes, I'm ready to invest in my health and smile

Yes, if affordable monthly payments are available

Payment plans are based on credit approval. How would you describe your credit history? *

Poor (under 579)

Fair (580-669)

Good (670-739)

Excellent (740+)

I do not need a payment plan

11. What is your approximate monthly household income? *

Under $3,000

$3,000-$5,000

$5,000-$7,500

$7,500+

Which location is closer to you? *

Houston, TX (Midtown)

Magnolia, TX

First Name *

Last Name *

Phone *

Email *

I consent to receiving transactional emails and SMS messages related to my dental implant inquiry and questionnaire submission, including delivery of my Dental Implant Guide.

One of our representatives will contact you to assist you in scheduling your dental implant consultation at FLOSS.