Do you have any broken or teeth missing? If yes, how many ?
*
All
6+
4 - 5
3 Or Less
What is your age group?
*
60 +
50 - 59
40 - 49
< 40
Please select the type of dental work/appliances you currently have in your mouth?
*
Denture Or Partial Denture
Bridge, Crown
Dental Implant
None Of The Above
Please select the amount of time your teeth have been missing? (Your jaw bone starts to shrink once you lose one or several teeth.)
*
I Still Have Them
1 - 6 Months
7 - 12 Months
1 + Years
Are you currently able to chew your food properly?
*
Yes
No
Are you trying to find a solution to eliminate the pain or discomfort you are experiencing?
*
Yes
No
Do you find yourself avoiding social gatherings, covering your smile or a lack of confidence due to your dental condition?
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Yes
No
Have you had a consultation for dental implants at another implant center such as OneSolution Dental Implant Centers?
*
Yes
No
Are you ready to start eating what you want, smile again and do something about your dental situation?
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Somewhat Ready
Very Ready
I Need Something FAST!
While dental insurance might cover a minimal amount for implant procedures, we offer affordable payment plans to cover the financial aspect of the procedure. Are you interested in a monthly payment plan?
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Yes I am interested in learning more about a payment plan
No I will not need a payment plan and will pay for the treatment outright
Monthly payment plans are available based on credit approval of the patient or with a co-signer. What’s your credit score?
*
(Poor) below 580
(Fair) 580 - 699
(Good) 700 - 739
(Excellent) 740+
Which county of South Florida do you live in:
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Select Place
Broward
Palm Beach
Miami-Dade
Martin
St. Lucie
Indian River
Collier
Monroe
Other
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Which location do you live closet to?
*
Palm Beach
Plantation
Are you aware that our implant center can give you new teeth and implants in just a few hours while you sleep?
*
Yes
No
What Is Your First Name?
*
What Is Your Last Name?
*
What is Your Best Email?
*
What Is Your Best Phone Number?
*