What's the biggest problem you're having with your teeth right now? *

I'm missing between 1-3 teeth

I'm missing more than 3 teeth

I want to get rid of my dentures

Have you had a dental implant consultation with a dentist before to address the issue? *

Yes

No

How ready do you feel now to do something about your situation? *

Somewhat ready

I am VERY READY to get my teeth and smile back!

Do you have dental insurance? *

Yes

No

What is the name of your insurance provider? *

Are you interested in financing options? *

Yes, I'm interested in financing options

No, I will NOT need financing

Which best describes your credit score? *

Under 600

601-649

650-700

701-790

791-850

Do you have someone with a credit score of 650 or higher who can co-sign for your treatment? *

Yes

No

Are you willing to pay out-of-pocket for your treatment? *

Yes

No

Which best describes your current household monthly income? *

Under $5,000

$5,000 to $8,000

Over $8,000

What is your age? *

60+

50-59

40-49

Under 40

What is your zip code? (Enter 5 digits only) *

Enter your name, email and phone number below so that we can send you your results.

Full Name *

Phone *

Email *

I understand, Medicare or Medicaid will not cover dental implants procedure or treatment.

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