Are you a Candidate for Dental Implants and a FREE 3D Implant Consultation?
Find out with our one minute questionnaire.
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What is your biggest dental challenge? (Select all that apply)
(Required)
I am missing a single tooth
I am missing multiple teeth
I am struggling with my traditional dentures
Most of my teeth are broken, decayed or missing
How long have you been struggling with this?
(Required)
Select One
Less than one month
Less than six months
Less than a year
More than a year
What has kept you from fixing your smile? (Select all that apply)
(Required)
Nothing! I am ready right now.
Cost of dental procedures
Fear of dental procedures
Time involved in dental procedures
Have not found a dentist that I am comfortable with yet
If it was affordable, how soon would you be ready to move forward with treatment?
(Required)
Select One
Now
In the next 30 days
In the next 6 months
I am in no rush, just researching options
How do you plan to pay for your dental implant treatment? (Select all that apply)
(Required)
Cash
Credit Card
Dental Insurance (please note: Medicaid not accepted)
3rd Party Healthcare Financing (CareCredit, LendingClub)
What is your current credit score range?
(Required)
Select One
Poor (350-550)
Fair (550-650)
Good (650-720)
Excellent (720+)
I don’t know my credit score
Select the option that best describes your situation.
(Required)
Select One
I can afford monthly payments of $300 - $500 and have money to put down
I have a set amount of cash that I can spend and need help finding a treatment plan that fits my budget
I am prepared to pay for my entire treatment up front
I do not currently have any money to afford treatment
Have you spoken to another dentist about treatment?
(Required)
Select One
Yes, I would like a second opinion
No, this will be my first consultation
What was the price range of the other dentist’s treatment plan?
(Required)
Select One
$500-$2,000
$2,000-$5,000
$5,000-$10,000
$10,000-$20,000
$20,000-$30,000
More than $30,000
What is most important to you about your implant dentist? (select all that apply)
(Required)
Lowest cost
Experience placing implants
Delivers highest quality
Financing options
Gentle and Caring
How did you hear about us?
(Required)
Google Search
Facebook - Instagram
Internet Ad
Other
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
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