How Long Have You Been Missing Your Teeth?

I'm Not Missing Teeth

Less Than A Year

More Than A Year

Do You Currently Have Any Of The Following Treatments?*

Crowns and/or Bridges

Partials

Dentures

None of the Above

Have You Experienced Any Type Of Insecurities Regarding The Way Your Teeth Look?

Yes

No

Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods?

Yes

No

What Is The Most Important Outcome You Are Seeking?

Function - Eating, Chewing, Talking

Aesthetics - Beautiful, Natural Looking Teeth

Both Are Equally As Important

What Is The Most Important Factor That Has Prevented You From Getting Treatment?

Time

Money

Fear

Can't Find The Right Dentist

What Is your Level of Urgency To Find Relief From Any Type Of Pain Or Discomfort That You May Be Feeling?

1 - Very Little, I'm Not In A Rush

2- Moderate, I-3 Months

3 - High, I'm Looking For Help Now!

Have You Had Treatment Plans From Other Doctors For Dental Implants Recently?

Yes

No

Are You The Decision Maker In Regards To Your Dental & Healthcare?

Yes

No

Are You Interested in Learning About Our Easy Monthly Payment Plans? If So, What Dollar Range Would You Like To Pay Monthly

No Financing

$50-149/Month

$150-$249/Month

$250-349/Month

Over $350/Month

Which Best Describes Your Current Credit Score?

Below 580

580-699

700+

I'm Not Sure

First Name *

Last Name *

Phone *

Email *

We will be using your information to contact you via phone call, sms messaging, and email.