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) *

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

Do You Understand That Medicare and Medicaid Do Not Cover Dental Implants, and Most Insurances Do Not Provide Coverage for Dental Implants? *

Yes

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. *

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? *

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

What Is Your Estimated Household Income (Before Taxes)? *

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? *

How Ready Do You Feel To Do Something About Your Situation? *

Somewhat Ready

Very Ready

I Need Something FAST!

What City And State Do You Live In? *

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? *

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What is the best time to contact you? *

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Evening