Are You Currently Experiencing A Lack Of Confidence In Social Situations or Find Yourself Hiding Your Smile? *

Yes

What Are Some Of The Things You Would Like To Improve About Your Smile?

Missing Teeth - I need to replace my missing teeth.

Stained Or Unattractive Teeth - I want my teeth to look attractive.

Tooth Alignment - My teeth are not straight.

Looking for a Smile Makeover

Nothing, I'm happy with my smile.

What Is The Biggest Problem That You’re Having With Your Teeth Right Now: *

I'm missing 1-2 teeth

I’m missing more than 2 teeth

I have chips or cracks visible in my smile

My teeth have gaps (large or small) or crowding.

How Important Is Preserving Your Natural Tooth Enamel? *

Mandatory with no exceptions.

Very important - I want to keep my natural teeth as natural as possible.

I don’t mind losing some enamel in the process if it means improving my overall smile.

What Has Kept You From Getting Your Smile Fixed? *

Nothing! I'm Ready Right Now!

Fear of Dental Procedures

Cost of Dental Procedures

Time Involved in Dental Procedures

I Haven't Found A Dentist I'm Comfortable With Yet

If You Could Fit Smile Makeovers Into Your Budget Are You Ready To Start Right Away? *

Yes

How Quickly Do You Want Results? *

As soon as possible. I don’t want to have to wait for a better smile any longer than I already have

I don’t mind waiting if it means better, longer-lasting results

As soon as I have gathered all of the information necessary to make the best decision

Have You Had Treatment Plans From Other Doctors For Smile Makeovers Recently? *

Yes

Do You Have Any Significant Damage To Your Teeth Such As Deep Decay? *

Yes, but only in my back teeth

Yes, in my front teeth

Do You Have Healthy Dental Enamel? *

No, in the past I have or currently have suffered from enamel erosion

Yes

I’m not sure

What Is The Most Important To You When Selecting A Dental Health Provider? *

Financing Options

Experience & Level Of Expertise

Flexibility Of Appointment Times

Price

Do You Understand That Medicare And Medicaid Do NOT Cover Cosmetic Dentistry, And Most Insurances Do NOT Provide Coverage For Cosmetic Dentistry? *

Yes

Approximately What Investment Range Are You Comfortable With? *

$1,500 - $4,000

$4,000 - $10,000

$10,000 - $20,000

$20,000 - $50,000

Not sure yet. Need to schedule my consultation

Are You Interested In A Payment Plan Option? Many Affordable Payment Plan Options Exist As Little As $65/Mo For A Single Tooth Or $260/Mo For A Full Smile Makeover *

Yes, I'm Interested In Affordable Payment Plan Options

No, I Will Not 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) 501-600

(Good) 601-649

(Very Good) 650-699

(Excellent) 700+

I don't know

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

Unfortunately, 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 Cosmetic Dental Procedure? *

Savings

Credit Card

Retirement Account

Other Loan (Home Equity, etc)

Help From A Relative

No, I Don't

What City And State Do You Live In? *

City
State

Last Step

Please use the form below to complete your questionnaire and claim your special offer on Cosmetic Dentistry!

First Name *

Last Name *

What Is Your Best Email Address? *

What Is Your Best Phone Number? *

Best Time To Contact You?