16009 FM 1325 Suite 200, Austin, TX 78728

What best describes the condition of your mouth? *

Missing a single tooth

Missing multiple teeth

Struggling with Full or Partial Dentures

Most of my teeth are in pretty bad shape

What dental procedures have you completed? *

Denture or Partial Denture

Bridge and/or Crown

Dental Implant

Most of my teeth are in pretty bad shape

What improvements are you most interested in? *

I want to be able to eat the foods I love again

I want to feel confident smiling

I want to get out of pain

All of the above

Have you been told you have Gum Disease or Periodontal Disease? *

Yes

No

Upon credit approval or with the help of a cosigner, payment plans are available. Which best describes your credit? *

(Very Poor) Under 500

(Poor) 500-649

(Good) 650-749

(Excellent) 750+

I don’t know

Unfortunately 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? *

Savings

Credit Card

Retirement Account (401k, etc.)

Other Loan (Home Equity, etc.)

Help from a relative

No, I don't

How much cash can you put down for your dental implants procedure? *

Less than $5,000

More than $5,000

Based on your credit score you may not qualify for financing without a co-signer. Do you have someone with 650+ credit history who has already AGREED to co-sign for you? *

Yes

No

What is the name of your co-signer and who are they to you? *

What is your Zip code? (this helps us know that we are reaching people in our area) *

What is your Full Name? *

What is your best email address? *

What is your best phone number? *

I agree to the terms & conditions provided by Scheduling Team, and by providing my phone number, I agree to receive text messages from Scheduling Team.

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