Are you missing one or more teeth? *

Yes

No

How Many Teeth Are You Missing? *

1

2

3

More than 3

Have you consulted a Dentist regarding your oral health? *

Yes

Yes, a while ago

No

Have you been told you need your teeth extracted? *

Yes

No

Other

Have you used dentures, a flipper, or bridge prior to implants? *

Yes

No

What bothers you the most about your present oral condition? *

What has prevented you from getting dental treatment in the past? *

Cost

Financial difficulties

Schedule

Fear of the Dentist

Not aware of options

Other

Other

Do you have Dental Insurance? *

Yes

No

Are you aware of the average fees for dental implants procedures? *

Yes

No

If you are interested in financing your treatment, which of the following options would suit you? *

3rd Party extended term financing (generally 700+ credit score)

Partial Finance and Self-Pay

Cash, Personal Savings

Credit Card

First Name *

Last Name *

Phone *

Email *

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