First Name

Last Name

Phone *

Email *

Treatment *

Implants

Crowns

Veneers

Other

Who is this treatment for? *

Myself

Someone else

Upper Arch

1. Upper Arch Photo Upload *

Lower Arch

2. Lower Arch Photo (Tongue to Roof) Upload *

Bite Down - Gums back

3. Our doctors need a good view of your natural bite. Teeth together, gums back and snap photo. *

Do you have any X-ray?

Yes

How many teeth are you missing? *

All

4-5

3 or Less

Do you have any of these dental solutions? *

Denture or Partial Denture

Bridge, Crown

Dental Implant

None of the above

How long have you been missing 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 unable to eat certain foods or have to modify the way you chew? *

Yes

Are you in any pain or experiencing discomfort? *

Yes

Do you have diabetes? *

Yes

Do you have periodontal/gum disease? *

Yes

Have you had a dental consultation with another dentist recently? *

Yes

How ready are you to do something about your situation? *

Somewhat Ready

Very Ready

I Need Something FAST!

Insurance typically doesn’t cover dental implants. However, affordable payment plans are available. Are you interested in learning about payment plan options? *

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

I understand, reducing my dental implant expense by 60% or more means saving as much as $50,000 off full-mouth and $25,000 off full-arch dental restorations over what I would pay locally. I believe this is a lot of money and I have better ways to spend my money than on over-priced dental implants. *

Agree

Disagree

Did you know many large U.S. dental chains charge over $30,000 per arch—yet have their teeth made in China? At HebeDoc, we’re not ok with that. Our approved dentists use only top U.S., Swiss, and German implant brands—Straumann, Nobel Biocare, and Zimmer—ensuring world-class quality at a fraction of the U.S. cost. I understand my travel expenses are an additional cost I pay myself and feel it’s reasonable if I’m saving thousands on dental treatment. I am open and interested in learning more about traveling to San Diego, Phoenix, or Cancun for treatment. *

Yes

I have a valid passport. (Note: not necessary in all locations) *

Yes

I agree to HebeDoc Terms and conditions , I have read the Privacy Policy and I agree that my given details including health data may be processed by HebeDoc for the purpose of obtaining quotes. This includes the transfer of my data to healthcare providers within and outside the EU. The consent can be revoked at any time with effect for the future.