Which condition best describes you?
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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?
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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)
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I Still Have Them
1-6 Months
7-12 Months
1+ Years
6+ Years
Are You Currently Unable To Eat Certain Foods Or Have To Modify The Way You Chew?
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Yes
No
Are You Currently Trying To Find Relief From Any Kind Of Pain Or Discomfort?
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Yes
No
Are You Currently Experiencing A Lack Of Confidence In Social Situations or Find Yourself Hiding Your Smile?
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Yes
No
Dental Implants are an investment, comparable to purchasing a new vehicle, and are not covered by Insurance. However, many affordable payment plan options exist. Are you interested in a payment plan option?
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Yes, I have good credit and would like financing arrangements.
Yes, I do not have great credit and will need other financial assistance.
No, I will pay out of pocket.
Payment plans are available based on credit approval of the patient or a co-signer. Which best describes your credit?
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(Very Poor) Under 500
(Poor) 501-600
(Good) 601-649
(Very Good) 650-699
(Excellent) 700+
I don't know
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?
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Yes
No
How Ready Do You Feel To Do Something About Your Situation?
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Somewhat Ready
Very Ready
I Need Something FAST!
What is your preferred language?
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English
Spanish
Full Name
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Phone
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Email
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