Which condition best describes you? *

I have 1 tooth missing

I have multiple teeth missing

I'm missing all of my teeth or most of my teeth

I'm Struggling With Traditional Dentures

Do you currently have any of these dental solutions? *

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) *

I Still Have Them

1-6 Months

7-12 Months

1+ Years

6+ Years

Which of the following are you experiencing? (Check all that apply) *

Unable To Eat Certain Foods

Have To Modify The Way You Chew

Pain Or Discomfort

A Lack Of Confidence In Social Situations

Find Yourself Hiding Your Smile

All of the Above

Dental Implants are an investment, comparable to purchasing a new vehicle, and are not usually covered by insurance. However, many affordable payment plan options exist. Are you interested in a payment plan option? *

Yes, I'm interested in a payment plan.

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? *

(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? *

Yes

Unfortunately it looks like you would not be able to qualify for our payment plan options. Do you have any other way to pay for a Dental Implant procedure? *

Savings

Credit Card

Retirement Account (401k, etc)

Other loan (Home Equity, etc)

Help from a relative

No, I don't

How Ready Do You Feel To Do Something About Your Condition? *

Somewhat Ready

Very Ready

I Need Something Fast!

Full Name

Phone *

Email *

By checking this box, I agree to the Terms of Use and to be contacted by email, phone number or text message, by the company to handle my request or promotional messages.

I understand the information disclosed in this form may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations and the HITECH Act. I understand that by hitting "Submit" I am opting into receiving text, emails, and phone calls relating to booking a dental implant consultation.