ARE YOU A CANDIDATE FOR DENTAL IMPLANTS?

DENTAL IMPLANT EVAULATION

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

I Have All My Teeth

I'm Missing One Tooth

I'm Missing Multiple Teeth

I'm Missing All My Teeth

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

Crowns and/or Bridges

Partials

Dentures

None of the Above

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

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? *

Time

Money

Fear

Can't Find The Right Dentist

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

Your credit score? *

Under 500

500-620

620-650

Above 700

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

Yes

No

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!! SAVE THOUSANDS

(this month only!)

Receive A Special Promotion That Can Save You Thousands! Plus Free Pricing Guide

Mention This Ad!

"Dental Implants Not Only Improved My Smile, But My Health Overall"

AFFORDABLE

TEETH IN ONE DAY

We understand your missing teeth contribute to

missing out on the foods you love, social moments, and inhibit the

basic human expression of smiling.

WE CAN HELP YOU.

Talk to Us:

(844) 763-3731

THEY'RE NOT JUST NEW TEETH ...

IT CHANGES YOUR LIFE.

*Real client testimonials

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