Please Provide Your Best Contact Info
Full Name
*
Phone
*
Email
*
Where Are You Located?
City
*
State
*
Postal code
*
Tell Us About Your Smile Challenges
What is your biggest dental challenge?
I am missing a single tooth
I am missing multiple teeth
I am struggling with traditional dentures
Most of my teeth are decayed, broken, or missing
How long have you been missing teeth? (The longer teeth are missing the more the jawbone shrinks.)
Less than a month
Less than 6 months
Less than 1 year
More than 1 year
Are you currently experiencing any pain or discomfort when eating or chewing?
yes
no
Are you unable to eat the foods you want or have to change the way you chew?
Yes
No
Have you ever found yourself hiding your smile or feeling less confident in social situations?
Yes
No
What has been the biggest roadblock in keeping you from fixing your smile?
Nothing! I'm ready right now!
Cost of dental procedures
Fear of dental procedures
Time involved in dental procedures
Haven't found a dentist I'm comfortable with yet
Where are you in your decision process?
I'm ready to invest now & start treatment
I'll be ready in the next 30 days
No rush, I'm still researching
Have you talked with another dentist about implants?
Yes, I'd like a second opinion.
No, this is my first consultation.
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What was the estimated cost of the proposed treatment plan?
$500 - $2000
$2000 - $5000
$5000 - $10000
$10000 - $15000
$15000 - $20000
$20000 - $25000
More than $25000
Do you want to learn more about low monthly payment options?
Yes
No
How Would You Rate Your Credit Score?
Poor (below 580)
Fair (580 - 640)
Good (640 - 720)
Excellent (720+)
What's MOST important to you about your implant dentist?
Is the lowest cost
Affordable payment options
Delivers the highest quality of dentistry
Provides a comfortable and caring patient experience
Is highly educated and experienced in implant dentistry
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Would you like to upload a photo of your smile?
Yes (instructions to upload your picture will show on next slide)
No
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List is empty.
Upload An Image of Your Smile By Clicking Below.
How would you like to be contacted?
Phone call
Text
Email
Everything.... Excited to get started!