Which Condition Best Describes You?
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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?
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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)
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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?
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Yes
No
Are You Currently Trying to Find Relief From Any Kind of Pain or Discomfort?
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Yes
No
Do You Understand That Medicare and Medicaid Do Not Cover Dental Implants, and Most Insurances Do Not Provide Coverage for Dental Implants?
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Yes
No
Are You Interested In A Payment Plan Option? Many Affordable Payment Plan Options Exist As Little As $65/Mo For A Single Implant Or $260/Mo For A Full Set Of Upper Or Lower Teeth.
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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?
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(Very Poor) Under 500
(Poor) 501-600
(Good) 601-649
(Very Good) 650-699
(Excellent) 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?
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Yes
No
What Is Your Estimated Household Income (Before Taxes)?
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Under $12,000
$12,000 - $23,999
$24,00 - $35,999
$36,000 - $49,999
$50,000 - $69,999
$70,000 - $94,999
$95,000 +
Unfortunately, It Looks Like You Might Not Be Able to Qualify for Our Payment Plan Options. Do You Have Any Other Way to Pay for a Dental Implant Procedure?
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Savings
Credit Card
Retirement Account
Other Loan (Home Equity, etc)
Help From A Relative
No, I Don't
How Ready Do You Feel To Do Something About Your Situation?
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Somewhat Ready
Very Ready
I Need Something FAST!
What City And State Do You Live In?
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City
State
Last Step
Please Use the Form Below to Complete Your Questionnaire and Claim Your Special Offer on Dental Implants!
First Name
*
Last Name
*
What Is Your Best Email Address?
*
What Is Your Best Phone Number?
*
What Is The Best Time To Contact You?
Morning
Afternoon
Evening