When was your last dental visit? *

1 year or less
1 to 3 years
3 to 5+ years
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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

Are you self-conscious or embarrassed by your teeth and or smile? *

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, I-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 interested in financing options? *

Yes I am!

No I will not need a payment plan

What Dollar Range Would You Like To Pay Monthly? *

$150-$249/Month

$250-349/Month

Over $350/Month

Payment plans are based on credit approval, you may also bring in co-signer. If you could guess, what is your credit score? *

500- 550

551 - 600

601 - 650

651 - 700

701+

I don't know my credit score

Do you work with state funded insurance? *

Yes

First Name *

Last Name *

Phone *

Email *

Postal Code *