Dental Implants Questionnaire 1 2 3 4 5 6 7 Why are you interested in dental implants?* Missing teeth Failed dental work Want to switch from dentures Broken or dead tooth Next How is this issue affecting you?* I am in a lot of pain It’s affecting my confidence I cannot chew or speak properly General health concerns Prev Next While dental implants may not be fully covered by insurance, we’re here to help with affordable payment options. Does a payment plan sound good to you?* Yes, I would like to learn more about payment plans No, I will cover any costs out of pocket Payment plan options are available and require credit approval for you or a co-signer. Is your credit score over 600?* Yes No I’m not sure Do you have a family member or friend with good credit who could co-sign for you?* Yes No Unfortunately, our payment plan options may not work for you at this time. Do you have other resources available to cover the cost of the implant procedure?* Savings Retirement Funds (ie. 401K or IRA) Credit Card Other Loan Help from a Relative No other way to pay Prev Next What’s your current level of readiness to take action and improve your situation?* Ready to start now Ready to start in the next 1 – 2 months I’m still looking into it and need more time Prev Next What’s your first name?* What’s you last name?* What’s the best email to reach you?* What’s the best phone number to reach you?* Please enter the numbers only Prev Next You're almost done! Select 'I accept' below to receive our assistance. By providing your information, you consent to being contacted by a Pinnacle Dental Group representative through text, email, or phone.* I accept Prev Next Submit my answers
