How Many Teeth Are You Currently Missing?
*
All
6+
4-5
3 or less
What Is Your Age?
*
60+
50-59
40+
<40
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
Are You Currently Unable To Eat Certain Foods Or Have To Modify The Way You Chew?
*
Yes
No
Relief Are You Currently Trying To Find Relief From Any Kind Of Pain Or Discomfort?
*
Yes
No
Are You Currently Experiencing A Lack Of Confidence In Social Situations or Find Yourself Hiding Your Smile? *
Yes
No
How Ready Do You Feel To Do Something About Your Situation?
*
Somewhat Ready
Very Ready
I Need Something FAST!
Dental Implant procedures are not covered by insurance. However, many affordable payment plans are available. Are you interested in a payment plan option?
*
Yes. I'm interested in affordable payment plan options
No. I've been saving for this type of procedure and 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?
*
(Very Poor) Under 500
(Poor) 500-649
(Good) 650-749
(Excellent) 750+
Do you own your own home?
Yes
No
What region of the country do you live in?
*
Orange County
Los Angeles County
San Diego County
Riverside County
Inland Empire
None of the above
What Is Your Full Name?
*
What Is Your Best Email?
*
What Is Your Best Phone Number?
*