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?