(925) 633-4337
1181 Boulevard Way
Walnut Creek, CA 94595
Find Out If You're A
Candidate For Dental Implants
Answer The Following Questions To Learn More About Our Pricing And Financing Options.
What Best Describes Your Condition?
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I Have All My Teeth
I'm Missing One Tooth
I'm Missing Multiple Teeth
I'm Missing All My Teeth
How Long Have You Been Missing Your Teeth?
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I'm Not Missing Teeth
Less Than A Year
More Than A Year
Do You Currently Have Any Of The Following Treatments?
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Crowns and/or Bridges
Partials
Dentures
None of the Above
Have You Experienced Any Type Of Insecurities Regarding The Way Your Teeth Look?
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Yes
No
Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods?
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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?
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Time
Money
Fear
Can't Find The Right Dentist
What Is your Level of Urgency To Find Relief From Any Type Of Pain Or Discomfort That You May Be Feeling?
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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?
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Yes
No
Are You The Decision Maker In Regards To Your Dental & Healthcare?
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Yes
No
Are You Interested in Learning About Our Easy Monthly Payment Plans? If So, What Dollar Range Would You Like To Pay Monthly
*
No Financing
$250-$349/Month
$350-$499/Month
Over $500/Month
Which Best Describes Your Current Credit Score?
*
Below 600
600-700
700+
I'm Not Sure
Co-Signer?
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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
By selecting no, we have no immediate way to send you the information that you are requesting.
*
Yes I consent to receive this information
I would like to schedule an appointment to talk in person
I would like to speak to someone via phone call to discuss
I do not want this information
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*
Last Name
*
Phone
*
Email
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