Which statement best describes your current dental situation? *

I’m missing most or all of my teeth

I’ve lost several teeth over time

I’m missing a few teeth

I still have nearly all my natural teeth

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

Yes, I avoid certain foods

Sometimes, depending on the food

No, I eat normally

Please select your age group: *

65 or older

55–64

45–54

Under 45

Have you been told you have gum disease, or do any teeth feel loose or unstable *

Yes, I’ve been diagnosed or noticed looseness

I’m not sure

Do you currently rely on any of the following dental solutions? *

Full or partial dentures

Fixed dental work (crowns or bridges)

One or more implants

None

How long have you been missing your teeth? *

I haven’t lost any

1-6 Months

7-12 Months

1+ Years

Are you experiencing pain, discomfort, in your teeth or gums? *

Yes, frequently

Occasionally

Do dental concerns impact your confidence or make you hide your smile? *

Yes, often

Sometimes

Not really

Have you spoken with a dental professional about implants before? *

Yes, I’ve had a consultation

No, not yet

How soon are you hoping to improve your health, diet, and smile? *

3-6 months

1-3 months

Immediately

Dental implant treatment is usually not covered by insurance, but payment options may be available. Which best applies to you? *

Yes, like to explore financing options

No, I would like to pay on my own

Implant treatment costs can vary widely, with monthly payment options sometimes available. Would you like to check possible eligibility? *

Yes, I’d like to see my options

Maybe later

No, not needed

Financing approval is based on credit. Which range best describes your situation? *

Below average

Average

Above average

Excellent

Which range best reflects your approximate monthly income? *

Below $60,000

$61,000–$70,000

Above $70,000

What’s your first name? *

And your last name? *

Where can we email you? *

Best number to reach you *