We Are Located In Elk Grove, CA. Are You Okay With Traveling To Our Office For Your Treatments? *

Yes

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

Do You Currently Have Any Of The Following Treatments?

Crowns and/or Bridges

Partials

Dentures

None of the Above

Have You Experienced Any Type Of Insecurities Regarding The Way Your Teeth Look?

Yes

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 The Decision Maker In Regards To Your Dental & Healthcare?

Yes

Major Dental Implant Treatment May Require Substantial Financial Investment And Is Not Covered By Insurance Or Medi-Cal. Have You Planned On How You Will Pay For The Work Needed? *

I Have Good Credit And Would Like Financing Arrangements.

I Will Pay Out Of Pocket.

I Do Not Have Great Credit And Will Need Other Financial Assistance.

I Have Not Given Thought To This

Should You Have Difficulty Getting Approved For Financing, Do You Have A Co-Signer To Help You That You Can Bring In For The Consultation? If You Have A Low Credit Score And Need Full Mouth Implants, You Will Need A Co-Signer. *

Yes, I Have A Co-Signer.

No, I Don't Have A Co-Signer.

Which Best Describes Your Current Credit Score?

Below 580

580-699

700+

I'm Not Sure

First Name *

Last Name *

Phone *

Email *

Postal code *