Which condition best describes you? *

Missing 1 tooth

Missing multiple teeth

Struggling with multiple dentures

Most of my teeth are in pretty bad shape

Do you currently have any of these dental solutions? *

Denture or partial denture

Bridge, crown

Dental Implant

None of the above

How Long Have You Been Missing Your Teeth? (The longer teeth are missing the more the jaw bone shrinks) *

I still have them

1 - 3 Months

3 - 6 Months

6 Months - 1 Year

1 Year+

Are You Currently Unable To Eat Certain Foods Or Have To Modify The Way You Chew? *

Yes

No

Are You Currently Trying To Find Relief From Any Kind Of Pain Or Discomfort? *

Yes

No

Are You Currently Experiencing A Lack Of Confidence In Social Situations or Find Yourself Hiding Your Smile? *

Yes

No

What's Kept You From Getting Your Smile Fixed? *

Nothing! I'm ready right now

Cost of Dental procedures

Fear of Dental procedures

Time involved with Dental procedures

Haven't found a Dentist i'm comfortable with

Dental Implant procedures are 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 plans

No, i will not need payment plan

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

(Very Poor) Under 500

(Poor) 501 - 600

(Good) 601 - 699

(Excellent) 700+

I don't know

Based on your credit score you may not qualify for financing without a co-signer. Do you have someone who would co-sign with you? *

Yes

No

How Ready Do You Feel To Do Something About Your Situation? *

Somewhat Ready

Vey Ready

I need something FAST!

When is the best time to contact you? *

Morning

Afternoon

First Name *

Last Name *

Email *

Phone *

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