How many teeth would you like to improve or replace for a healthier smile?
*
All
6+
4-5
3 Or Less
Could you please share your age with us?
*
60+
50-59
40-49
<40
Are you currently struggling with any of these dental solutions?
*
Denture or Partial Denture
Bridge, Crown
Dental Implant
None of the above
How long have you experienced missing teeth?
*
I Still Have Them
1-6 Months
7-12 Months
1+ Years
Are there any foods you're finding difficult to eat, or have you been changing the way you chew?
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Yes
No
Are you currently seeking ways to alleviate any pain or discomfort you may be experiencing?
*
Yes
No
Do you ever feel like your confidence could use a boost in social settings, or do you find yourself holding back your smile?
*
Yes
No
Have you had the chance to discuss dental implant options with another dentist yet?
*
Yes
No
How prepared do you feel to take action toward improving your situation?
*
Somewhat Ready
Very Ready
I Need Something FAST!
While dental implant procedures may not be covered by insurance, there are often affordable payment plans available. Would you like more information on 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
The average cost for dental implant procedures nationally falls between $22,000 and $55,000. Payment plans can start as low as $300 per month. Would you be interested in exploring payment plan options, or are you comfortable proceeding without?
*
Yes, please tell me if I might qualify for a payment plan
No, I don't need a payment plan
Payment plans are available based on the credit approval of the patient or a co-signer. How would you describe your credit situation?
*
(Poor) Under 660
(Fair) 660-699
(Good) 700-739
(Excellent) 740+
Based on your credit situation you may need a cosigner. Do you have anyone who can cosign for you?
Yes
No
Could you share which category best fits your current household monthly income?
*
Under $5,000
$5,000 to $8,000
Over $8,000
Full Name
*
Email
*
Phone
*
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