Which Conditions Best Describe You? *

I'm unhappy with the look of my teeth (color, shape, defects, etc.)

I'm missing one or more teeth and would like to get them replaced.

I already have veneers and would like to have them redone.

The position or misalignment of my teeth could be improved.

How soon would you like to start treatment? *

This Month

1-3 Months

4-6 Months

6+ Months

Are you willing and able to travel to Fort Lauderdale, FL? *

Yes

Which condition best describes you? *

I only want 1-5 veneers.

I'm considering 6-15 veneers.

I would like a full set of veneers (16+)

I'm not looking for veneers.

Are you missing any teeth that you would like to restore? *

No Missing Teeth

Some Missing Teeth

Many Missing Teeth

I'm not sure

Who are you filling this out for? *

Myself

Spouse

Child

Other

Are you interested in learning about our easy monthly payment plans? If so, what dollar range would you like to pay monthly? *

No Financing

$150-249 / Month

$250-349 / Month

Over $350 / Month

Financing options are available based on your credit history. Which option best describes your credit? *

Poor Credit (Below 580)

Fair Credit (580-650)

Good Credit (650-720)

Great Credit (720+)

For helpful financing options, typically a credit score of 650+ is the sweet spot. Could you please select one of the following? *

I have a cosigner with a qualifying credit score.

I have an alternate form of payment (credit card, family/friend, personal loan, etc.)

I selected the wrong credit score on the original form.

I don't have a 650+ cosigner or any payment options.

Would you like us to use your basic information to pre-qualify for financing options? It's great to know your options at the first appointment! (No hard credit check.) *

Yes, I'm interested.

No, not right now.

I would like links sent to apply on my own device.

Perfect, to get you prequalified we will need some basic information.

Date of birth

Last 4 of Social Security Number

Please Choose *

Proceed with Pre-Qualification

Don't Pre-Qualify Yet

Don't worry! Some people can still qualify for financing. We work with several great financing companies. We can send some application links to your device and you can give it a shot! It doesn't hurt to apply with family members as well! Would you like to try? *

Yes

Maybe now is not the time for Smile Design. However, we are still more than happy to see you as a new patient for routine care or any other dental needs! Would you like to schedule a new patient exam? *

Yes

Awesome! Please provide your information below:

First Name *

Last Name *

Phone *

Email *