Are You:
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An adult considering Invisalign for yourself?
A teen considering Invisalign for yourself?
A parent considering Invisalign for your child?
Have You Ever Worn Braces?
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Yes
No
Which Best Describes Your Smile?
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Overbite: Upper front teeth close in front of the lower teeth.
Underbite: Lower teeth protrude past upper front teeth.
Crossbite: Upper and lower jaws don’t line up.
Gap Teeth: Extra spaces between teeth.
Open Bite: Top and bottom teeth don’t meet.
Crooked Teeth: There isn’t enough room in the jaw for teeth to fit normally.
Generally Straight: Teeth When you just want a more beautiful smile.
Mix of Baby and Permanent Teeth: Phase 1 orthodontic treatment for growing children with a mix of baby and permanent teeth.
Why Are You Thinking About Straightening Your Teeth?
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My dentist recommended it
I’m self-conscious about my smile
Getting Married or Special Event
I just want straighter teeth
When It Comes To Invisalign, Are You?
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Informed - I’ve done my research
Curious - I know a bit and want to learn more
Skeptical - It’s too good to be true
What Matters To You Most?
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Speed of treatment
Discreet treatment
Comfort
Low monthly payments
Quality of treatment
Has Your Smile Affected Your Self Confidence In The Dating World, Business Arena, Or At School?
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Yes
No
Which Of The Following Do You Think Is Most Important, When It Comes To Straightening Your Teeth?
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Straightening the teeth without anyone noticing
Continuing to eat whatever I want
Having minimal mouth and gum irritation
Maintaining a healthy mouth and teeth during treatment
Minimal impact on family schedule with a low number of dental visits
How Determined Are You To Get Rid Of This Dental Problem On A Scale Of 1-10(10 Being The Highest)?
Select A Number
1
2
3
4
5
6
7
8
9
10
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What Investment Range Are You Comfortable With? (Approximately)
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$1,000 - $2,000
$2,000 - $5,000
$5,000 - $7,000
Not sure yet. Need to schedule my consultation
Are You Interested In Financing Options? Many Affordable Financing Options Exist As Little As $74/Mo.
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Yes. I'm Interested In Affordable Financing Options
No, I Will Not Need Financing Options
Payment plans are available based on credit approval of the patient or a co-signer. Which best describes your credit?
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(Very Poor) Under 500
(Poor) 501-600
(Good) 601-649
(Very Good) 650-699
(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 with good credit history who would co-sign with you?
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Yes
No
What Is Your Estimated Household Income (Before Taxes)?
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Under $12,000
$12,000 - $23,999
$24,00 - $35,999
$36,000 - $49,999
$50,000 - $69,999
$70,000 - $94,999
$95,000 +
Unfortunately, It Looks Like You Would Not Be Able To Qualify For Our Payment Plan Options. Do You Have Any Other Way To Pay For An Invisalign Procedure?
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Savings
Credit Card
Retirement Account
Other Loan (Home Equity, etc)
Help From A Relative
No, I Don't
If Invisalign Is The Right Choice, I Would Like To Start Treatment:
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Immediately
Sometime this year
In 1 to 3 months
In 4 to 6 months
Sometime next year
What City And State Do You Live In?
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City
State
Last Step
Please use the form below to complete your questionnaire and claim your special offer on Invisalign!
First Name
*
Last Name
*
What Is Your Best Email Address?
*
What Is Your Best Phone Number?
*
Best Time To Contact You?
*
What Is The Best Time To Contact You?
Morning
Afternoon
Evening
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