Schedule Your Free Consultation in less than 5 minutes below:

First Name *

Last Name *

Email *

Phone *

I agree to receive marketing messaging from Smile Dental Center at the phone number provided above. I understand I will receive 5 messages a month, data rates may apply. Reply STOP to opt out.

Are You Currently Wearing Dentures? *

Yes

What Is The Most Important Outcome You Are Seeking? *

Function - Eating, Chewing, Talking

Aesthetics - Beautiful, Natural Looking Teeth

Both are Equally Important

How Long Have You Been Missing Your Teeth? *

I am Not Missing Teeth

Less Than a Year

More Than a Year

Please Describe Your Current Oral Health And Any Challenges You Are Facing: *

Do You Have a Household Income of $24,000+ (Can Be Your Income Plus a Partner or Spouse) + Have a Credit Score of 570 or Higher? *

Yes

Are You Willing to Travel to Our Practice in Gibsonia, PA *

Yes

What Is Your Best Day and Time of the Week for a Consultation? *

Preferred Consultation Date *

What Is Your Timeline To Receive Treatment? *

I'm Flexible, No Rush

Within 1-3 Months

I Need Help Now

Have You Seen Another Dentist About Your Issues? *

No, This Is My First Consultation

Yes, But I Did Not Feel Comfortable With The Other Practice

Yes, I Am Looking To Compare Prices

Have You Had Treatment Plans From Other Doctors For Dental Implants Recently? *

Yes

Are You Familiar With The "All-On-4" Treatment? *

Do You Currently Have Any Of The Following Treatments? *

Dentures

Partials

Crowns and/or Bridges

None of the Above

What Would You Like To Change About Your Smile? *

Approximate Number of Teeth Needing Implants? *

Do You Have Any Comments or Questions?