Where would you like your complimentary consultation to take place? *

Huntley, IL

Machesney Park, IL

Which condition best describes you? *

Missing 1 Tooth

Missing Multiple Teeth

Struggling With Traditional Dentures

Most Of My Teeth Are In Pretty Bad Shape

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? (the longer teeth are missing the more the jaw bone shrinks) *

I Still Have Them

1-6 Months

7-12 Months

1+ Years

6+ Years

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

Yes

Are you currently trying to find relief from any kind of pain or discomfort? *

Yes

Are you currently experiencing a lack of confidence in social situations or find yourself hiding your smile? *

Yes

Dental Implant procedures are not covered by insurance. However, many affordable payment plan options exist. 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? *

Under 500

501-600

601-649

650-699

700+

I don't know

Based on your credit score you may not qualify for financing without a co-signer. Do you have someone with good credit history who would co-sign with you? *

Yes

Unfortunately it looks like you would not be able to qualify for our payment plan options. Do you have any other way to pay for a Dental Implant procedure? *

Savings

Credit Card

Retirement Account (401k, etc)

Other loan (Home Equity, etc)

Help from a relative

No, I don't

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

Somewhat Ready

Very Ready

I Need Something FAST!

What is your name? *

Last name *

What is your best email address? *

What is your best phone number? *

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