What Best Describes Your Condition? *

I Have All My Teeth

I'm Missing One Tooth

I'm Missing Multiple Teeth

I'm Missing All Teeth

How Long Have You Been Missing Your Teeth? *

I'm Not Missing Teeth

Less Than A Year

More Than A Year

Do You Currently Have Any Of The Following Treatments? *

Crowns and/or Bridges

Partials

Dentures

None of the Above

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? *

Which Of The Following Are You Experiencing? *

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

Time

Money

Fear

Can't Find The Right Dentist

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

Yes

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

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

Very Little, I'm Not In A Rush

Moderate, Within 1-3 Months

High, I'm Looking For Help Now

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

Are You Interested In Learning About Financing Options? *

Yes. I'm interested in affordable payment plan options

No. I will not need a payment plan

We work with finance companies that we see approvals as low as a 660 credit score. If needed, do you have someone willing to sign for you? *

Yes

If you don't have someone willing to sign for you, did you have another plan in place to move forward with treatment? *

Yes

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

Yes

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

We Are Located in Lakewood Ranch, FL. Are You Willing To Travel To Our Location? *

Yes

Do you have Blue Cross Blue Shield medical insurance? *

Are you interested in a payment plan option?

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?

Below 580

580-699

700+

I'm Not Sure

First Name *

Last Name *

Cell Phone *

Email *

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