Am I A Candidate For Dental Implants?

Find out if you qualify in less than 2 mins. The purpose of this form is to help assist in the assessment of your eligibility as a potential candidate for dental implants.

12 Questions

How many teeth are you currently missing? *

Yes

What is your age? *

Internet

Flyer / Mailer

Poster / Sign / Billboard

Referral / Word-of-Mouth

Other

Do you currently have any of these dental solutions? *

Yes

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

Yes

Are you currently unable to eat certain foods or have to modify the way you chew? *

Yes

Are you currently trying to find relief from any kind of pain or discomfort? *

Yes

Are you currently experiencing a lack of confidence in social situations or find yourself hiding your smile? *

Yes

Have you had a dental implant consultation with another dentist?

Yes

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

Somewhat Ready

Very Ready

I Need Something FAST!

Dental Implant procedures are not covered by insurance. However, many affordable payment plans are available. Are you interested in a payment plan option? *

Yes, I'm interested in affordable payment plan options

No. I've 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? *

(Poor) Under 660

(Fair) 660-699

(Good) 700-739

(Excellent) 740+

Please Enter Your Details

Email *

Phone *

Full Name *