How Many Teeth Are You Currently Missing? *

Less than 3 teeth

4-5 teeth

6+ teeth

I am missing ALL of my teeth

Select the option below that best describes your situation: *

I want to replace ALL my teeth with new permanent teeth

I want to replace my upper or lower set of teeth

I only want to have a couple teeth replaced

I don't want any of my teeth replaced

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

None of the above

Have You Had A Dental Implant Consultation With Another Dentist? *

Yes

No

What Has Been A Factor Preventing You From Seeking This Treatment? *

Time

Money

Lack of Knowledge

Fear

How Ready Do You Feel To Do Something Financially About Your Situation? *

Not Ready At All

Somewhat Ready

Very Ready

I Need Something FAST!

Dental Implant procedures are not covered by insurance. However, many affordable payment plan options exist. 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

Payment plans are available based on credit approval of the patient or a co-signer. Which best describes your credit? *

Under 660

660-699

700-739

740+

What Is Your Household Annual Income? *

Under $45K

$45K-$80K

Over $80K

Payment Plans for dental implants typically start at around $300 a month. Will you be able to successfully pay this each month for your treatment?

Yes

No

Dentures are usually an affordable alternative to dental implants. Would you be interested in being fitted for dentures?

Yes

No

We cannot move forward without seeing you for an in-person consultation. This no pressure, no judgement, no cost appointment is FREE and will give us the details we need to discuss the available options and pricing with you. Are you available to meet at our clinic in Scottsdale? *

Yes

No

Is there anything that might prevent you from attending your scheduled consultation? *

What Time Of Day Would Be Best For Us To Contact You To Discuss Your Needs? *

Before 9:00AM

9:00AM - 11:00AM

11:00AM - 1:00PM

1:00PM - 3:00PM

3:00PM - 5:00PM

After 5:00PM

What Is Your Zip Code? (Enter 5 Digits Only) *

What Is Your First Name? *

What Is Your Last Name? *

What Is Your Best Email Address? *

What Is Your Best Phone Number? *

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