Which condition best describes you? *

1 tooth is missing/bad

Multiple teeth are missing/bad

Struggling with traditional dentures

Most of my teeth are in pretty bad shape

Where are most of your bad or missing teeth? *

Top

Bottom

Both

Are you able to eat comfortably? *

I chew mostly on one side

I have pain when I chew

I limit the types of foods I can eat

I am able to eat comfortably

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

Yes

Please explain why you would like a second opinion? *

This is my first consult

I did not feel confident in the doctor at the other practice

I did not feel comfortable at the other practice

I would like to compare prices

Patients without teeth lose as much as 25% of their bone width within the first year. The longer you wait to replace missing teeth, the more advanced your bone loss will become.

How urgent is this treatment to you? *

I want this done ASAP. I'm in pain / tired of feeling sick and I'm ready to improve the quality of my life

I want this done 1-3 months from now. I definitely want this treatment, I just need a little more time

I'm still researching, I don't know yet

What has been the biggest roadblock to fixing your smile? *

Nothing! I'm ready right now.

Cost of dental procedures

Fear of dental procedures

Time involved in dental procedures

I haven't found a dentist I'm comfortable with

What is most important to you about your implant dentist? *

The lowest possible cost

Affordable payment options

Flexibility of appointment times

Provides a comfortable patient experience

My dentist is highly educated and experienced in implants

Dental implant procedures are not covered by MediCal, MediCare or HMO insurance. However, several affordable payment plans exist.

Are you interested in payment plan options? *

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

Healthcare financing companies will ask for a source of income.

Do you have a job/source of income? *

Yes, I have a job/source of income (other than SSI)

No, I don't have a job/source of income

Payment plans are available based on credit approval of the patient or a co-signer.

Which best describes your credit? *

Based on your credit score you may not qualify for financing without a co-signer.

Do you have someone with a credit score of 650 or higher who would co-sign with you? *

Yes

It looks like you would not be able to qualify for our payment plan options.

Do you have any other way to pay for a Dental Implant procedure? *

Do you understand that Medicare and Medicaid do NOT cover dental implants, and most insurance plans have annual limits for dental implants? *

Yes

Do you understand that Medicaid and Medicare do NOT cover dental implants, and most insurance plans have annual limits for dental implants? *

Yes

Your first name? *

Your last name *

What is your best phone number? *

What is your best email address? *

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