What Best Describes Your Condition? *

I Have All My Teeth

I'm Missing One Tooth

I'm Missing Multiple Teeth

I'm Missing All My Teeth

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

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

Yes

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, 1-3 Months

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

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

Yes

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

Yes

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

What Best Describes Your Current Credit Score? *

Below 580

580-699

700+

I'm Not Sure

First Name *

Last Name *

Phone *

Email *

Which Location Is Most Convenient? *

Santa Maria, CA

Templeton, CA

I confirm that I want to receive communication from Central Coast Dental Implant Center using any contact information I provide.