How many missing or broken teeth do you have? *

All

6+

4-5

3 or less

What is your age? *

60+

50-59

40-49

<40

Do you currently have any of these dental solutions? *

Denture or Partial Denture

Bridge, Crown

Dental Implant

None of the above

How long have you been missing your teeth? *

I still have them

1-6 months

7-12 years

1+ years

Are you currently unable to eat certain foods or have to change the way you chew? *

Yes

No

Are you currently experiencing any pain or discomfort? *

Yes

No

Do you feel the need to hide your smile or experience a lack of confidence in social situations due to your teeth? *

Yes

No

How ready are you to do something about your situation? *

Somewhat ready

Very Ready

I need something NOW!

Dental implant procedures aren't covered by insurance. However, affordable payment plans are available. Are you interested in a payment plan? *

Yes. I'm interested in affordable plan options.

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

Payment plans are available based on credit approval of the patient or a co-signer. Which of these best describes your credit? *

750+

650-749

500-649

Under 500

What is your current monthly income?

Less than $3,000/mo

$3,000 - $6,000/mo

$6,000 - $9,000/mo

$9,000/mo +

First Name

Last Name

Email *

Phone *

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