Need help?

(804) 589-5665

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

How Long Have You Been Missing Your Teeth? *

Which of the following treatments do you currently have? *

Crowns and/or Bridges

Partials

Dentures

None of the above

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

Are you currently in any pain? *

Yes

No

Are you experiencing any type of insecurities regarding the way your teeth look? *

Yes

No

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

Yes

No

What's the most important factor preventing you from seeking treatment? *

Time

Money

Fear

Can't Find The Right Dentist

What's your level of urgency to find relief from any pain or discomfort? *

Very Little, I'm Not In A Rush

Moderate, 1-3 Months

High, I'm Looking For Help Now!

Have you been treated by any Dentists for implants recently? *

Yes

No

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

(Poor) 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

Phone *

Email *