Implant Survey

1

What Best Describes Your Condition?* This field is required.

Broken, loose, or discolored teeth

I'm missing multiple teeth

I'm missing one tooth

I'm missing all my teeth or in dentures

2

How Long Have you Been Living with Tooth Loss?* This field is required.

0-2 Years

2-5 Years

5-10 Years

Over 10 Years

3

What is the most important outcome you are seeking?* This field is required.

Function - Eating, Chewing, Talking

Aesthetics - Beautiful, Natural-Looking Teeth

Both are equally as important

4

What is the most important factor that has prevented you from getting treatment?* This field is required.

Time

Fear

Money

Can't find the right dentist

5

Upon credit approval or with the help of a cosigner, payment plans are available! Which best describes your credit?* This field is required.

(Very Poor) Under 500

(Poor) 500-649

(Good) 650-749

(Excellent) 750+

I'm not interested in financing

6

You May Be A Candidate For Dental Implants! Fill Out The information and Our Highly Trained Team Will Reach Out To You With Your Results!* This field is required.

First Name

Last Name

Phone Number

Zip Code

Email

7

Get Page URL

8

gclid

9

fbclid

10

SMC APP NAME

11

SMC APP NUMBER

12

SMC APP EMAIL