1. Which condition best describes you? *

Missing 1 Tooth

Missing Multiple Teeth

Struggling With Traditional Dentures

Most Of My Teeth Are In Pretty Bad Shape

Some Of My Teeth Are In Bad Shape

2. Do you currently have any of these dental solutions? *

Denture or Partial Denture

Bridge, Crown

Dental Implant

None Of The Above

3. How long have you been missing your teeth? *

I Still Have Them

1-6 Months

7-12 Months

1-5 Years

6+ Years

4. Are you currently unable to eat certain foods or have to modify the way you chew? *

Yes

No

5. Are you currently trying to find relief from any kind of pain or discomfort? *

Yes

No

6. Are you currently experiencing a lack of confidence in social situations or find yourself hiding your smile? *

Yes

No

7. How soon are you looking to do something about your situation? *

I'm Ready Now

Within The Next Few Months

Longer Than A Few Months

I'm Just Starting My Research And I'm Not Sure When I'll Be Ready

8. Dental implant procedures are a significant investment, and many patients choose to utilize financing options to make them more affordable. Would you be interested in exploring a payment plan? *

Yes, I'm interested in a payment plan.

No, I've been saving for this type of procedure and will not need a payment plan.

9. Payment plans are available. Which best describes your credit? *

A. (Very Poor) Under 500

B. (Poor) 501-600

C. (Good) 601-649

D. (Very Good) 650-699

E. (Excellent) 700+

F. I don't know

9a. 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? *

Yes

No

9b. It looks like you would not be able to qualify for our payment plan options. Do you have any other way to pay for a Dental Implant procedure? *

A. Savings

B. Credit Card

C. Retirement Account

D. Other loan

E. Help from a relative

F. No I don't

10. Have you ever had a Dental Implant consultation before? *

Yes

No

11. What Is Your Name? *

12. What Is Your Best Phone Number? *

13. What Is Your Best Email Address? *

Text Message Confirmation *

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