How Many Teeth Are You Currently Missing? *
All my teeth are missing
6+
4-5
3 or less
What age bracket are you in *
65+
50-59
40-49
Younger than 40
Are You Currently Putting Up With Dentures, Partials, or Bridges That Just Aren't Giving You the Solid, Comfortable Bite You Deserve? *
Yes, I have dentures, or partial dentures
Yes, I have bridge or crown
Yes, I have I have a implants
None of the above
How Many Months or Years Have Passed Since You Lost Those Teeth...(Jaw Bone Loss Gets Worse The Longer You Wait)? *
I still have all my teeth
1-6 months
7-12 months
1 or more years
Is Your Diet Restricted Because Chewing Foods You Once Enjoyed—Like Steak, Nuts, or Corn-on-the-Cob—is Now Difficult or Painful? *
Yes
No
Are You Actively Seeking Relief from Nagging Dental Pain or Discomfort Right Now? *
Yes
No
Does Embarrassment Over Your Teeth Cause You to Hide Your Smile or Feel Less Confident in Social or Business Settings? *
Yes
No
Have You Had A Dental Implant Consultation With Another Dentist? *
Yes
No
How Serious Are You About Taking Action to Permanently Resolve These Dental Issues in the Near Future? *
I Need Something FAST!
Very Ready
Somewhat Ready
Most insurance doesn't cover dental implants fully. Will exploring affordable monthly payment plans be helpful for you? *
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
To see which financing options you might qualify for, how would you rate your current credit? *
(Needs Improvement) Under 660
(Fair) 660-699
(Good) 700-739
(Excellent) 740+
What Is Your Approximate Monthly Household Income *
Under $5,000
$5,000 to $8,000
Over $8,000
What Is Your 5-Digit Zip Code? (To Confirm Service Area) *
What Is Your First Name?
*
What Is Your Last Name?
*
Your Best Email Address?
*
Your Best Contact Phone Number?
*
Consent
*
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