What is your biggest challenge with your oral health? *

I am missing a single tooth

I am missing multiple teeth

Most of my teeth are broken, decayed or missing

I am struggling with traditional denture(s) or partial(s)

How long have you been struggling with this challenge? *

Less than a month

Less than a year

Less than 5 years

More than 5 years

Do you currently have any of these solutions in your mouth? *

Dental Implant

Crown

Bridge

Denture

Partial

None of the above

Are you struggling to eat or chew certain foods? *

Yes

Do you need relief from dental pain or discomfort? *

Yes

Are you holding your smile back due to lack of confidence? *

Yes

What has kept you from fixing your smile? *

Nothing! It just happened and I am ready right now.

Fear of dental procedures

Time involved in dental procedures

Cost of dental procedures

I have not found a dentist I am comfortable with yet

Depending on your insurance and finances, dental implant procedures may be cost prohibitive for some. Are you interested in affordable payment options? *

Yes

Maybe

Payment Plan Options are based on credit approval of the applicant. Which option below best describes your credit? *

Very Poor (Under 500)

Poor (501 - 600)

Fair (601 - 650)

Good (651 - 700)

Very Good (701 - 800)

Excellent (800+)

I don't know

Based on your credit status, IF you do not qualify for payment plans, do you have someone with good credit that would be willing to co-sign for you? *

Yes

Which of the following are most important to you about your implant dentist? *

Cost

Quality

Gentle & Caring

Payment Plans

Experience with Dental Implants

Comprehensive Care (Under One Roof)

Have you seen another dentist for your current issue? *

Yes

How do you plan to pay for your treatment? *

Cash

Credit Card

Dental Insurance

3rd Party Financing

First Name *

Last Name *

Phone *

Email *