What Best Describes Your Condition?
*
I Have All My Teeth
Missing One Tooth
Missing Multiple Teeth
Missing All My Teeth
How Long Have You Been Missing Your Teeth?
*
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 Experienced Any Type Of Insecurities Regarding The Way Your Teeth Look?
*
Yes
No
Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods?
*
Yes
No
What Is The Most Important Outcome You Are Seeking?
*
Function - Eating, Chewing, Talking
Aesthetics - Beautiful, Natural Looking Teeth
Both Are Equally As Important
What Is The Most Important Factor That Has Prevented You From Getting Treatment?
*
Time
Money
Fear
Cannot Find The Right Dentist
What Is your Level of Urgency To Find Relief From Any Type Of Pain Or Discomfort That You May Be Feeling?
*
1 - Very Little, Not In A Rush
2- Moderate, 1-3 Months
3 - High, Looking For Help Now!
Have You Had Treatment Plans From Other Doctors For Dental Implants Recently?
*
Yes
No
Are You The Decision Maker In Regards To Your Dental & Healthcare?
*
Yes
No
Are You Interested in Learning About Our Easy Monthly Payment Plans?
*
Yes, Interested in Easy Monthly Payments
No, Not Interested in Financing
Which Best Describes Your Current Credit Score?
*
Below 580
580-699
700+
Not Sure
First Name
*
Last Name
*
Phone
*
Email
*
What Location Is Most Convenient For You
*
Miles City
Sidney
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