Are Dental Implants for you?

dental implant evaluation

What Best Describes Your Condition? *

I Have All My Teeth

I'm Missing One Tooth

I'm Missing Multiple Teeth

I'm Missing All My Teeth

How Long Have You Been Missing Your Teeth? *

I'm Not Missing Teeth

Less Than A Year

More Than A Year

Do You Currently Have Any Of The Following Treatments?*

Crowns and/or Bridges

Partials

Dentures

None of the Above

Have You Experienced Any Type Of Insecurities Regarding The Way Your Teeth Look? *

Yes

Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods? *

Yes

What Is The Most Important Outcome You Are Seeking? *

Function - Eating, Chewing, Talking

Aesthetics - Beautiful, Natural Looking Teeth

Both Are Equally As Important

What Is The Most Important Factor That Has Prevented You From Getting Treatment? *

Time

Money

Fear

Can't Find The Right Dentist

What Is your Level of Urgency To Find Relief From Any Type Of Pain Or Discomfort That You May Be Feeling? *

1 - Very Little, I'm Not In A Rush

2- Moderate, I-3 Months

3 - High, I'm Looking For Help Now!

Have You Had Treatment Plans From Other Doctors For Dental Implants Recently? *

Yes

Are You The Decision Maker In Regards To Your Dental & Healthcare? *

Yes

Are You Interested in Learning About Our Easy Monthly Payment Plans? If So, What Dollar Range Would You Like To Pay Monthly *

No Financing

$50-149/Month

$150-$249/Month

$250-349/Month

Over $350/Month

Which Best Describes Your Current Credit Score? *

Below 580

580-699

700+

I'm Not Sure

First Name *

Last Name *

Phone *

Email *

I understand the information disclosed in this form may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations and the HITECH Act.

COMPLETE THIS EVALUATION TO INSTANTLY DISCOVER:

If Dental Implants Are For you
What treatment options are available
Pricing & financing options

BONUS!!

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