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

Are You Currently Wearing Dentures? *

Yes

No

Have You Seen Another Dentist About Dental Implants? *

No, This is my first consultation

Yes, I did not feel comfortable with the other practice

Yes, I'm looking to compare pricing

If This Is A Second Opinion What Type Of Implant Solution Are You Looking For? *

Fixed Full Arch

Implant Supported Denture

Single Implant

Traditional Denture

Not Sure

What Is Your Primary Issue With Your Smile Right Now? *

Tooth Pain

Missing Teeth

Insecurities about the way you look

All of the above

What Is The Most Important Factor That Has Stopped You From Getting Treatment Previously? *

Time

Money

Fear

Can't Find The Right Dentist

Implants Are Capable Of Changing Lives - What Is Your Most Desired Outcome In A Full Mouth Rehabilitation? *

Function - Eating, Chewing, Talking

Aesthetics - Beautiful, Natural Looking Teeth

Both Are Equally As Important

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

Yes

No

How Fast Are You Looking To Change The Way You Smile? *

Very little, I'm in no rush

Moderate, Within 1-3 months

High, I need help now

Are You Familiar With An "All On 4" Treatment? *

Yes

No

Unfortunately, We Do Not Accept Grants, Clinical Trials, Or Medicaid. Were You Planning On Using Any Of These To Pay For Your Dental Implant Procedure? *

Yes

No

Are You Interested In Learning About Financing Options? *

Yes

No

Which option most closely represents your credit score? *

Below 499

500 - 599

600 - 679

680 - 720

721+

Do You Have A Co-Signer To Help With Financing Approval? *

Yes

No

Do You Own Your Home? *

Yes

No

Currently Paying Mortgage

For Your Convenience, We Will Send You The Customized Information In Regards To Dental Implants Via Text And Email *

Yes send me the information

No, I do not wish to receive information regarding pricing for dental implants

By Selecting No, We Have No Immediate Way To Send You The Information That You Are Requesting. *

Yes I consent to receive this information

I would like to schedule an appointment to talk in person

I would like to speak to someone via phone call to discuss

I do not want this information

Our Practice Is Located In Meridian, ID. Are You Willing To Travel To This Location? *

Yes

No

First Name *

Last Name *

Postal Code *

Cell Phone *

Email *

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