Do you have any broken or teeth missing? If yes, how many ? *

All

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

Are you trying to find a solution to eliminate the pain or discomfort you are experiencing? *

Yes

Do you find yourself avoiding social gatherings, covering your smile or a lack of confidence due to your dental condition? *

Yes

Have you had a consultation for dental implants at another implant center such as OneSolution Dental Implant Centers? *

Yes

Are you ready to start eating what you want, smile again and do something about your dental situation? *

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? *

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: *

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

What Is Your First Name? *

What Is Your Last Name? *

What is Your Best Email? *

What Is Your Best Phone Number? *

I Consent to Receive SMS Notifications *

I Consent to Receive SMS Notifications, Alerts & Upcoming Details from OneSolution® Dental Implant Centers. Message frequency may vary. Message & data rates may apply. Text HELP for assistance. You may reply STOP to unsubscribe at any time.

I Consent to Receive the Occasional Marketing Messages *

I Consent to Receive Occasional Marketing SMS Messages from OneSolution® Dental Implant Centers. Message frequency varies. Message and data rates may apply. Reply STOP to opt out at any time.