Implant Form

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.

A couple of months

1-2 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 to me

4

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

Time

Fear

Money

I can't find the right dentist

5

What is your level of urgency to find a solution for your dental needs?* This field is required.

Very little, I'm not in a rush

Moderate, 1-3 months

High, I'm looking for help now!

6

Have you had a consultation or treatment plans from other dentists for dental implants?* This field is required.

Yes

No

7

Upon credit approval or with the help of a co-signor, 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 don't know

I don't want to finance, I have money saved

8

You may be a candidate for dental implants! Fill out the information below and our highly trained team will reach out to you with your options!* This field is required.