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

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Are you currently in any pain? *

Yes

Does your condition have a negative impact on your ability to eat or chew certain foods? *

Yes

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

Have you had a dental implant consultation with another dentist? *

Yes

How ready do you feel to do something about your situation? *

High, I'm ready to take action now.

Moderate, In the next 1-3 months.

I'm just exploring right now.

Are you currently experiencing a lack of confidence in social situations or find yourself hiding your smile? *

Yes

What is your desired outcome? *

Restore my smile

Improve my chewing function

Both

Other

Dental implant procedures are not covered by insurance or Medicaid and we do not offer free medical trials. 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 am aware of the potential cost for implants and will not need financing options.

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

(Excellent) 750+

(Great) 700-749

(Good) 650-699

(Fair) 600-649

(Cosigner needed) Under 599

Do you own your own home? *

Yes

Which best describes your current household monthly income? *

Over $8,000

$3,000 to $8,000

Under $3,000

Which location is closest to you?

Arizona

Utah

Colorado

Open to traveling

First Name *

Last Name *

Enter your best email *

Phone *

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