What best describes your current condition? *

I have all of my teeth

I'm missing one tooth

I'm missing multiple teeth

I'm missing all of my teeth

Are you currently in any pain?

Yes

No

How long have you been missing teeth?

I still have them

1-6 Months

7-12 Months

1+ Years

When was the last time you were seen by a dentist? *

Within a year

More than 2 years

More than 5 years

10+ years

What is your desired outcome? *

Restore my smile

Improve my chewing function

Both

Other

Dental Implant procedures are not covered by insurance. However, many affordable payment plans are available. Are you interested in a payment plan option? *

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.

Which of the options below most accurately represents your current credit score? *

(Excellent) 750+

(Good) 650-749

(Fair) 600-649

(Cosigner needed) Under 599

Do you own your own home? *

Yes

No

Which best describes your current household monthly income? *

Over $8,000

$4,000 to $8,000

Under $4,000

First Name *

Last Name *

Enter your best email *

Phone *

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