How many teeth are you missing in total? *

1-3 teeth

More than 3 teeth

Almost or all my teeth

I am not missing any

Have you experienced any pain or discomfort while eating? *

Constantly

Sometimes

Rarely

On a scale of 1 to 10, how confident do you feel with your current smile? *

1-4 (Not confident)

5-7 (I’m okay with it)

8-10 (Confident)

How long have you been experiencing issues with your teeth? *

Less than 6 months

6 months to 2 years

More than 2 years

Do you have a job or a source of income if you're considering financing your dental treatment through healthcare financing companies? *

Yes, employed

Retired

Unemployed

Disabled

If Approved, Which Best Describes The Maximum Budget You Can Spend Towards Your Dental Treatment Each Month? *

$300 to $499 per month

More than $500 per month

None of these fit within my budget

How do you intend to cover potential out-of-pocket costs for dental implant treatment, considering limited insurance coverage? *

Savings or personal funds

Third party or credit card financing

Based on your knowledge of dental implant treatments, is this something that you can fund completely from your savings/personal fund or would you need financing to help with part of your treatment? *

Yes, I can

No, I cannot and I would need additional support with financing options

I do not know what traditional costs are for dental implant treatments

Traditional costs for dental implant treatments can range, starting at $3,000 for a single tooth and up to $25,000 for a full row of teeth. (this may be different from what you are actually quoted in our office). Knowing this, is this something that can be funded completely from your savings/personal fund? *

Yes, it can

No, it cannot and I would need additional support with financing options

Interested in financing? Please select the option below that best describes your credit history. *

Excellent Credit (660 and above)

Good Credit (620-660)

Low Credit (Below 620)

In the event of challenges securing financing approval, do you have a co-signer with a credit score of at least 650 who can provide assistance? *

Yes

No

What is your relationship to your co-signer? *

Spouse

Parent

Will your co-signer be able to come to the consultation appointment with you or be available by phone for 10 to 20 minutes if they cannot attend the consultation appointment? *

Yes, they can

No, they cannot come to the appointment or be available by the phone

Dental implant treatment can start at $3,500 for a single tooth and $25,000 for a whole arch of teeth. Is that an investment your co-signer will be open to cosigning with you? *

Yes

No

Although we have a special offer for the first appointment, we do expect new patients to respect our time and show up for their appointment. Do you commit to showing up for your appointment at the time it is scheduled? *

Yes, I can commit to being on time

I might need a reminder closer to the date

I'm uncertain at the moment

Although we have a special offer for the first appointment, we do expect new patients to respect our time and show up for their appointment. Do you commit to showing up for your appointment at the time it is scheduled? *

Yes, I can commit to being on time

I might need a reminder closer to the date

I'm uncertain at the moment

When is the best time to contact you? *

Mornings (8am-11am)

Afternoons (11am-3pm)

Late Afternoon (3pm-5pm)

First Name *

Last Name *

Phone *

Email *

Zip code *