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How Many Missing Or Broken Teeth Do You Have?

All

4-5

3 Or Less

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What is Your Age?

60+

50-59

40-49

<40

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Do you currently have any of these dental solutions?

Denture or Partial Denture

Dental Bridge or Crown

Dental Implant

None of the Above

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How Long Have You Been Missing Your Teeth? (The longer teeth are missing the more the jaw bone shrinks)

I Still Have Them

1-6 Months

7-12 Months

1+ Years

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Are You Currently Unable To Eat Certain Foods Or Have To Modify The Way You Chew?

Yes

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Are You Currently Trying To Find Relief From Any Kind Of Pain Or Discomfort?

Yes

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

Yes

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Have You Had A Dental Implant Consultation With Another Dentist?

Yes

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How Ready Do You Feel To Do Something About Your Situation?

Somewhat Ready

Very Ready

I Need Something FAST!!!

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Dental Implant procedures are not covered by insurance. However, many affordable payment plans are available from medical financing companies. Are you interested in exploring payment plan options from a medical financing company? (Please note that we are unable to accept Medicaid, dental grants or clinical trials and we do not offer in-house financing.)

Yes, I am interested in affordable payment plan options

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

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National averages for dental implant procedures can range from $22,000 to $55,000. Payment plans start at $300. Are you interested in exploring payment plan options from a medical financing company, or still continue without?

Yes, please tell me if I qualify for a payment plan

No, I don't need a payment plan

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Payment plans from a medical financing company are available based on credit approval of the patient or a co-signer. Which best describes your credit?

Poor (Under 660)

Fair (660-699)

Good (700-739)

Excellent (740+)

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Which best describes your current household monthly income?

Under $5,000

$5,000 to $8,000

Over $8,000

Almost Finished. Where can we send your results?

First Name

Last Name

Email *

Phone *

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