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Dental Implant Forms
1
How Many Missing Or Broken Teeth Do You Have?
*
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All
6+
4-5
3 or Less
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2
What Is Your Age?
*
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60+
50-59
40-49
<40
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3
Do You Currently Have Any of These Dental Solutions?
*
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Denture or Partial Denture
Bridge/Crown
Dental Implant
None of the Above
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4
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
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5
Are You Currently Unable To Eat Certain Foods Or Have To Modify The Way You Chew?
*
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Yes
No
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6
Are You Currently Trying To Find Relief From Any Kind Of Pain Or Discomfort?
*
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Yes
No
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7
Are You Currently Experiencing A Lack Of Confidence In Social Situations or Find Yourself Hiding Your Smile?
*
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Yes
No
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8
Have You Had A Dental Implant Consultation With Another Dentist?
*
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Yes
No
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9
How Ready Do You Feel To Do Something About Your Situation? *
*
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Somewhat Ready
Very Ready
I Need Something Fast
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10
Do you currently have Blue Cross Blue Shield Medical PPO or FEP coverage?
*
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Yes
No
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11
Dental Implant procedures may not be covered by insurance. However, many affordable payment plans are available. Are you interested in a payment plan option?
*
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Yes. I'm interested in affordable payment plan options
No. I've been saving for this type of procedure and will not need a payment plan
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12
Payment plans are available based on the patient's or a co-signer's credit approval. Which best describes your credit?
*
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(Poor) Under 660
(Fair) 660-699
(Good) 700-739
(Excellent) 740+
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13
National averages for dental implant procedures can range from $22,000 to $55,000. Payment plans start at $300/mo. Would you like to see if you qualify for payment plans, or still continue without?
*
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Yes, please tell me if I might qualify for a payment plan
No, I don't need a payment plan
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14
Name
*
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First Name
Last Name
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15
Email
*
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example@example.com
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16
Phone Number
*
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Please enter a valid phone number.
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17
Preferred Method of Contact?
*
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Email
Phone
Text
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18
Preferred Method of Contact?
*
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Morning 8 am - 11 am
Noon 12 pm
Afternoon 1 pm - 5 pm
Other
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19
Opt-in for text and email updates to receive the latest news and offers for potential savings on your treatment.
*
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I Accept
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