What best describes your current dental condition? *

I have all my teeth, but they are failing

I’m missing one tooth

I’m missing multiple teeth

I’m missing all of my teeth

I wear dentures or partials

How has your dental condition affected your life? (Select all that apply) *

Difficulty eating certain foods

Pain or discomfort

Avoiding social situations/photos

Feeling older than I am

It affects my health or daily life

Professional Life

Have you seen another dentist or implant office about this before?

No, this is my first consultation

Yes, but I did not feel comfortable

Yes, I’m comparing options

Yes, but treatment was too expensive

Select All That Apply - Do You Feel That Tooth Loss Has Affected Your: *

Cost

Fear or anxiety

Time

I couldn’t find the right office

I wasn’t ready until now

How soon are you hoping to improve your smile? *

Immediately

Within 1–3 months

Within 6 months

I’m still researching options

If you qualify for treatment, how are you most likely planning to pay? *

Savings/personal funds

3rd Party Financing/monthly payments

Combination of savings and financing

401(k), retirement, or investments

Help from family/spouse

I’m not sure yet

Are you interested in learning about our financing and monthly payment options? *

Yes

No

Maybe depending on cost

Which range best represents your self-reported credit score? *

Below 550

551–600

601–650

651–700

701+

Some financing programs may require a co-signer for the best approval options. Would you have someone available to assist if needed? *

Yes, I have someone who would cosign

Possibly

No, I would apply alone

I have other payment options available

For Your Convenience, We Will Send You The Customized Information In Regards To Pricing For 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

Is There Anything Else You Would Like Us to Know About Your Dental Needs or Concerns? *

First Name *

Last Name *

Postal Code *

Phone *

Email *