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Are you willing to share your story so our future patients can see your amazing smile transformation? *

Yes (Save Thousands)

No (no savings)

What is the biggest problem that you’re having with your teeth right now? *

I’m missing 1-2 teeth

I’m missing more than 2 teeth

I want to get rid of my dentures

I need to have 1 or multiple teeth removed

If you have dentures, what issues do you have with them? (Select all that apply) *

How long have you been missing your teeth? *

I still have them

1-6 months

6 Months to 1 year

1 Year plus

Are you able to eat the foods you love with no discomfort? *

I have to limit the types of foods I can eat

It hurts when I chew

I chew mostly on one side of my mouth

I am able to eat comfortably with no issues

How are your teeth affecting your life? ( Select all that apply) *

How soon do you want to get your teeth/smile fixed? *

As soon as possible

Within the next 3-6 months

In about a year

I’m still researching. I don’t know yet.

What’s kept you from getting your smile fixed? *

Nothing! I’m ready right now

Cost of dental procedures

Fear of dental procedures

Haven’t found a Dentist I’m comfortable with

If payment plans were an option, is that something you would be interested in? *

Yes - I’m interested in a payment plan

No – I will not need a payment plan

Payment plans are available based upon credit approval of the patient or a co-signer. Which best describes your credit? *

(Very Poor) Under 500

(Poor) 501-600

(Good) 600-700

(Excellent) 700+

Based on your credit, you will most likely not be approved for dental implants. Do you have someone with good credit history who could co-sign with you? *

Yes

No

We do expect patients to respect our time and show up for their appointments. Do you commit to showing up for your appointment on time (once you’re scheduled)? *

Yes, I commit to showing up for my consultation on time

No, I cannot commit to showing up on time for my consultation

Please let us know the best day(s) for you to come in for your dental implant consultation and we will contact you to confirm an exact date. *

Please let us know the best time(s) of day for you to come in for your dental implant consultation and we will contact you to confirm an exact time. *

Morning

Afternoon

Evening

First Name *

Last Name *

Address *

City *

State/Province *

Zip/Postal code *

Email *

Phone *