What Dental Services Are You Interested In? *

Tongue or Lip Tie

Clear Aligners / Braces

Myofunctional Therapy / Mouth Breathing

ALF Therapy / Crowded Teeth

I Have Other Concerns

How Old Is Your Child? *

0-3 Years

4-7 Years

8-12 Years

13+ Years

What Is Your Main Concern That We Can Help You With? *

I Want My Child To Nurse Or Bottle Feed Better

I Think My Child Has a Tongue Tie

I Want Help With Mouth Breathing

I Want My Child to Sleep Better

I Want My Child to Have Straighter Teeth

I Have Other Concerns

These Services May Not Be Covered By Insurance. However, There May Be Affordable Monthly Payment Plan Options. Are You Interested In A Payment Plan Option? *

Yes. I am Interested in affordable payment plan options.

No. I've been saving and will not need a payment plan.

This Office Does Not Participate With Medicaid

Payment Plans Are Available Based on Credit Approval of the Patient or Co-signer. Which Best Reflects Your Credit Score? *

Under 600

600-649

650 - 800

No Credit Score

Based On Your Credit Score You May Not Qualify For Financing Without A Co-Signer. Do You Have Someone With Good Credit History Who Would Co-Sign With You? *

Yes

Unfortunately It Looks Like You Would Not Be Able To Qualify For Our Payment Plan Options. Do You Have Any Other Way To Pay For A Dental Implant Procedure? *

Savings

Credit Card

Retirement Account (401k, etc)

Other Loan (Home Equity, etc)

Help from a relative

No, I don't

How Ready Do You Feel To Address Your Concerns? *

I Am Interested To Learn More

I Am Ready To Do Something

I Want To Start As Soon As Possible

Contact Details *

If You Are Ready to Set Up Your Free Consult, Please Complete the Following Form So We May Contact You for Scheduling

Name *

Email *

Phone *

By clicking submit I agree to terms & conditions provided by Centreville Family Dentistry - Growth & Ortho. By providing my phone number, I agree to receive text messages or be contacted through phone/email about my dental needs.