Which Condition Best Describes You? *

Missing 1 tooth

Missing multiple teeth

Struggling with traditional 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 Implants

None of the above

How Long Have You Been Missing Your Teeth? *

I still have them

1-3 months

3-6 months

6 months to 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 denture procedures

Fear of dental procedures

Time involved with dental procedures

Haven't found a dentist i'm comfortable with

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

Yes, i'm interested in affordable payment plan options

No. I don't need a 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) 500 - 600

(Good) 600 - 700

(Excellent) 700+

I don't know

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

Somewhat ready

Very ready

I need something FAST!

First Name *

Last Name *

Email *

Phone *

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