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All On 4 (Qualification Survey) - SDI
1
Which condition best describes you?
*
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Select which condition is most relevant to you.
Missing 1 Tooth
Missing Multiple Teeth
Struggling with Traditional Dentures
Most of my Teeth are in Pretty Bad Shape
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2
Do you currently have any of these dental solutions?
*
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Denture or Partial Denture
Bridge or Crown
Dental Implant
None of the Above
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3
How Long Have You Been Missing Your Teeth?
(The longer teeth are missing the more the jaw bone shrinks)
*
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I Still Have Them
1-6 Months
7-12 Months
1+ Years
6+ Years
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4
Which of the following are you experiencing?
(Check all that apply)
*
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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
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5
Will you require "Early Super Release" or a "Payment Plan"?
*
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Our patients can pay using an early release of Super for dental treatment (This is a done-for-you service). We also offer affordable payment plans ranging from $35/week for a single Dental Implant ($6,500 total) to $140-$145/week for a Full Fixed Arch ($27,000-$29,500 total), as well as other options in between.
This can give you a brand-new smile in as little as 1 to 3 days. *
I would like to use my Super to pay for my treatment.
I'm interested in affordable payment plan options.
I will not need a payment plan.
$35 - $145 per week is too much, I can't afford it.
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6
Payment plans are available based on the credit approval of the patient or a co-signer. Please answer the following questions to see if you can qualify.
Are you an Australian Permanent Resident?
YES
NO
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7
Are you employed Full Time (minimum 25 hours per week), an aged Pensioner (65+ years of age) OR a Veteran Affair Pensioner?
Yes
No
None of the above
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8
Please confirm which of the below options best describes you?
Self-funded Retiree
Part-time Employment is less than 25 hours
Carer's pension / Widow’s pension / Disability pension
None of the above
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9
If you're a Self-funded Retiree, please confirm if you could provide the following if needed.
* Copy of recent utility bill * Copy of last 2 months bank statements * Copy of superannuation statement, and a * Copy of Driver’s License, Aged Pension Card OR Veterans Card. *
YES
NO
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10
If Part-time Employee is less than 25 hours, please confirm if you could provide the following if needed.
* Copy of recent utility bill * Copy of last 2 months bank statements * Copy of superannuation statement, and a * Copy of Driver’s License, Aged Pension Card OR Veterans Card. *
YES
NO
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11
If you're on a Pension, please confirm if you could provide the following if needed.
* Copy of recent utility bill * Copy of last 2 months bank statements * Copy of superannuation statement, and a * Copy of Driver’s License, Aged Pension Card OR Veterans Card. *
YES
NO
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12
Many of our patients pay for this life-changing procedure with their Super funds.
Please confirm which best describes you.
I have $10k-$15k in my Super & would like to learn more about how I can access these funds for my dental implant treatment
I have $15k-$30k in my Super & would like to learn more about how I can access these funds for my dental implant treatment
I have $30k-$50k in my Super & would like to learn more about how I can access these funds for my dental implant treatment
I have less than $10k in my Super.
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13
Unfortunately, it looks like you would not be able to qualify for paying for your dental treatment with Super.
Do you have any other way to pay for your procedure?
Savings
Credit Card
Other Loan (Home Equity, etc)
Help from relative
No, I don't
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14
We will call you to discuss your options for implant treatment & our payment plan options. This is purely an informational call, and there are no obligations whatsoever.
*
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After speaking with us, you can book an initial consultation with our Principal Dentist. NOTE: A $50 REFUNDABLE deposit is required to secure your consult, which will be refunded to you on the day of the appointment or credited towards your treatment if you decide to proceed with treatment. *
Yes I will show up & would like to speak with you first to learn more about dental implants and your payment plan options.
No. I'm just looking around at the moment.
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15
What is your Name?
*
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First Name
Last Name
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16
Best Email Address?
*
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example@example.com
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17
Best Phone Number?
*
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Please enter a valid phone number.
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