Full Name
*
Email
*
Phone
*
What best describes your current condition?
*
I have all of my teeth
I'm missing one tooth
I'm missing multiple teeth
I'm missing all of my teeth
When was the last time you were seen by a dentist?
*
Within a year
More than 2 years
More than 5 years
10+ years
What is your desired outcome?
*
Restore my smile
Improve my chewing function
Both
Other
Dental Implant procedures are not covered by insurance. However, many affordable payment plans are available. Are you interested in a payment plan option?
*
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.
Which of the options below most accurately represents your current credit score?
*
(Excellent) 750+
(Good) 650-749
(Fair) 600-649
(Poor) Under 599
Do you own your own home?
*
Yes
No
Which best describes your current household monthly income?
*
Over $8,000
$4,000 to $8,000
Under $4,000