What Best Describes Your Condition? *

I Have All My Teeth

I'm Missing One Tooth

I'm Missing Multiple Teeth

I'm Missing All My Teeth

How Long Have You Been Missing Your Teeth? *

I'm Not Missing Teeth

Less Than A Year

More Than A Year

How many teeth require implants? *

Less than Four

Four or more, less than complete arch

Full arch - upper

Full arch - lower

Complete upper and lower arch

Do You Currently Have Any Of The Following Treatments?* *

Crowns and/or Bridges

Partials

Dentures

None of the Above

Does Your Condition Have A Negative Impact On Your Ability To Eat Or Chew Certain Foods? *

Yes

What Is The Most Important Outcome You Are Seeking? *

Function - Eating, Chewing, Talking

Aesthetics - Beautiful, Natural Looking Teeth

Both Are Equally As Important

What Is The Most Important Factor That Has Prevented You From Getting Treatment? *

Time

Money

Fear

Can't Find The Right Dentist

What Is Your Level Of Urgency To Find Relief From Any Type Of Pain Or Discomfort That You May Be Feeling? *

1 - Very Little, I'm Not In A Rush

2- Moderate, I-3 Months

3 - High, I'm Looking For Help Now!

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

Yes

Are You Interested In Learning About Our Easy Monthly Payment Plans? If Yes, What Dollar Range Would You Like To Pay Monthly *

No Financing

$150-$249/Month

$250-349/Month

Over $350/Month

Which Best Describes Your Current Credit Score? *

Below 580

580-699

700+

I'm Not Sure

First Name *

Last Name *

Email *

Phone *