ARE YOU A CANDIDATE FOR DENTAL IMPLANTS?

DENTAL IMPLANT EVAULATION

Our practice is located in Chino Hills, CA. Are you willing to travel to this location? * *

Yes

No (too far)

Best Describes Condition of TeethWhat Best Describes Your Condition? * *

Missing Teeth

Have Multiple Issues with My Teeth

Chipped Teeth

How Long Have You Been Missing Your Teeth? *

I'm Not Missing Teeth

Less Than A Year

More Than A Year

Do You Currently Have Any Of The Following Treatments? * *

Yes! I am prepared to invest in my smile

No, I am not

Have You Experienced Any Type Of Insecurities Regarding The Way Your Teeth Look? * *

Stains or discoloration

Chipped or broken teeth

Gaps between teeth

Misaligned teeth

Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods? *

Yes

No

What Is The Most Important Outcome You Are Seeking? * *

Function - Eating, Chewing, Talking

Aesthetics - Beautiful, Natural Looking Teeth

Both Are Equally As Important

What Is The Most Important Factor That Has Prevented You From Getting Treatment? *

Yes, I will answer

No, I will not (do not submit)

What Is your Level of Urgency To Find Relief From Any Type Of Pain Or Discomfort That You May Be Feeling? *

1 - Very Little, I'm Not In A Rush

2- Moderate, I-3 Months

3 - High, I'm Looking For Help Now!

Have You Had Treatment Plans From Other Doctors For Dental Implants Recently? * *

Yes

No

Are You The Decision Maker In Regards To Your Dental & Healthcare? * *

Yes

No

Most Dental Implant procedures are not covered by insurance. However we offer many payment plans that make it quite affordable and offer low monthly rates. Are you interested in a payment plan? * *

Yes I am!

No I will not need a payment plan

Are You Interested in Learning About Our Easy Monthly Payment Plans? If So, What Dollar Range Would You Like To Pay Monthly * *

No Financing

$50-149/Month

$150-$249/Month

$250-349/Month

Over $350/Month

For your convenience, we will send you the customized information in regards to pricing for dental implants via text and email * *

Yes send me the information

No, I do not wish to receive information regarding pricing for dental implants

First Name *

Last Name *

Phone *

Email *

Postal code *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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I understand the information disclosed in this form may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations and the HITECH Act. I understand that by hitting "Submit" I am opting into receiving text, emails, and phone calls relating to booking a dental implant consultation.

COMPLETE THIS EVALUATION TO

INSTANTLY DISCOVER:

If You're A Candidate For Dental Implants.

What treatment options are available for you.

Pricing and financing options.

BONUS!!

Receive A Special Promotion That Can Save You Hundreds!

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