Dental Implants

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Which of the following best describes your current dental situation?* This field is required.

I have all my teeth

I’m missing one tooth

I'm missing multiple teeth

I'm missing all my teeth

2

What’s your main reason for wanting dental implants?* This field is required.Pick the best fit — you can share more later

I want to chew confidently and eat what I love

I'm ready to smile without holding back

I want relief from dental pain

I want a better alternative to dentures

My dental work keeps failing - I want a lasting solution

3

Do you currently have Medicaid?* This field is required.

YESNO

4

What dental insurance do you have?* This field is required.If uninsured, type ”None”

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How would you describe your credit score?* This field is required.Only used if you decide to explore payment plans.

Excellent (750 or above)

Good (650–749)

Fair (600–649)

Poor (Below 600)

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Financing typically requires a credit score of 650 or higher. Do you have someone who could co-sign for financing if needed?Only used if you decide to explore payment plans.

YESNO

7

Do you currently own a home?Only used if you decide to explore payment plans.

YESNO

8

What’s your total household monthly income? Only used if you decide to explore payment plans.

Over $8,000

$4,000 to $8,000

Under $4,000

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Is there anything else you'd like to share?

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Contact Information* This field is required.We keep your information private and use it only to follow up about your inquiry or dental care. By submitting, you agree to receive a call, text, or email from our team.

First Name

Last Name

Please enter your email

Please enter your phone

Zip Code

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utm_campaign

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utm_keyword

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gclid

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fbc

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First Name

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Last Name

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Email

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Phone

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ZIP

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Get Page URL

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