FILL OUT THE FORM BELOW TO GET YOUR PERSONALIZED TREATMENT PLAN ESTIMATE BEFORE YOU COME IN
Please fill out the questions to find out how we can help you.
First Name
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Last Name
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Email
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Phone
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Which Condition Best Describes You?
Missing One Tooth
Missing Multiple Teeth
Struggling With Traditional Dentures
Most Of My Teeth Are In Bad Shape
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Do You Currently Have Any Of These Dental Solutions?
Denture Or Partial Denture
Dental Implants
Bridge Crown
None Of The Above
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How Long Have You Been Missing Your Teeth? (The Longer Teeth Are Missing, The More The Jawbone Shrinks.)
I Still Have Them
1-3 Months
3-6 Months
6 Months to 1 Year
1 year +
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Are You Currently Trying To Find Relief From Any Kind Of Pain Or Discomfort?
Yes
No
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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 Am Comfortable With
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Would You Like To Know How Much You'll Be Approved For Before Your Consultation? We will run a soft credit check in order to let you know how much you're approved for. Your credit will NOT be affected by this check.
Yes, I'd Like To Be Pre-Approved For Financing Options
No, I Do Not Want To Know How Much I'm Approved For
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Payment plans are available based on credit approval of the patient or a co-signer. Which best describes your credit?
Excellent (720+)
Good (680-720)
Fair (620-680)
Below Fair (600-620)
Poor (Below 599)
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How Ready Do You Feel To Do Something About Your Situation?
Somewhat Ready
Very Ready
I Need Something Fast!
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