What Is Your Primary Issue With Your Smile Right Now? *

Tooth Pain

Missing Teeth

Insecurities about the way you look

All of the above

What dental solution are you using today? *

Full or partial dentures

Bridges or crowns

Dental implant(s)

I’m not using any solution

How long have your teeth been missing? (The longer your teeth are missing, the more your jaw bone shrinks.) *

I Still Have Them

1-6 Months

7 Months - 1 Year

More than 1 Year

What Is The Most Important Factor That Has Stopped You From Getting Treatment Previously? *

Time

Money

Fear

Can’t Find The Right Dentist

Have You Seen Another Dentist About Dental Implants? *

No, This is my first consultation

Yes, I did not feel comfortable with the other practice

Yes, I’m comparing my options

Which of the following challenges are you facing because of your teeth? (Select all that apply) *

Trouble eating or chewing comfortably

Pain or discomfort

Avoiding smiling or social situations

Feeling less confident about your appearance

Concern about your oral health

Impact on daily life (work, relationships, etc.)

Dental Implants are generally not covered by insurance. However, many affordable payment plan options exist. Are you interested in a payment plan option? *

Yes. I'm interested in affordable payment plan options

No. I have been saving for this type of procedure and will not need a payment plan

Payment plans are available based on credit approval of the patient or a co-signer. Which best describes your credit? *

(Very Poor Credit) Under 500

(Poor Credit) 501–600

(Fair Credit) 601–650

(Good Credit) 651–700

(Excellent Credit) 701+

I’m not sure

How Urgently Do You Want to Change Your Smile? *

Very little, I'm in no rush

Moderate, Within 1–3 months

High, I need help now

First Name *

Last Name *

Postal Code *

Phone *

Email *

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