How many teeth are you missing in total?

1-3 teeth

More than 3 teeth

Almost or all my teeth

I am not missing any

What is your age?

60+

50-59

40-49

<40

Do you currently have any of these dental solutions?

Denture or Partial Denture

Bridge, Crown

Dental Implant

None of the above

How scared of the dentist are you?

Not At All Scared

A Little Scared

Moderately Scared

Very Scared

Extremely Scared

How Long Have You Been Missing Your Teeth? (The longer teeth are missing the more the jaw bone shrinks)

I Still Have Them

1-6 Months

7-12 Months

1+ Years

Are You Currently Experiencing A Lack Of Confidence In Social Situations or Find Yourself Hiding Your Smile?

Yes

How do you intend to cover potential out-of-pocket costs for dental implant treatment, considering limited insurance coverage?

Savings or personal funds

Payment plan through the dental clinic

Credit card financing

Do you have a job or a source of income if you're considering financing your dental treatment through healthcare financing companies?

Yes, employed

Retired

Unemployed

Disabled

Interested in financing? Please select the option below that best describes your credit history.

Excellent (700 and above)

Good Credit (650-699)

Low Credit (below 650)

Although we have a special offer for the first appointment, we do expect new patients to respect our time and show up for their appointment. Do you commit to showing up for your appointment at the time it is scheduled?

Yes, I can commit to being on time

I might need a reminder closer to the date

I'm uncertain at the moment

When is the best time to contact you?

Morning (9am-12pm)

Afternoon (12pm-3pm)

Late Afternoon (3pm-5pm)

How would you like to be contacted?

Phone Call

Text me

E- Mail

Any

I agree to receiving text messages and phone calls from the dental office in order to confirm an appointment time. I understand I can opt-out at any time by replying STOP. Message & data rates may apply.