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Full Mouth Dental Implants
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Full Mouth Dental Implants
Pricing
Amazing Results
- Patient Stories
- Before & After Photos
Additional Treatments
Our Advantage
Locations
Contact Us

Full Mouth Dental Implants
Pricing
Amazing Results
- Patient Stories
- Before & After Photos
Additional Treatments
Our Advantage
Locations
Contact Us

Menu

Full Mouth Dental Implants
Pricing
Amazing Results
- Patient Stories
- Before & After Photos
Additional Treatments
Our Advantage
Locations
Contact Us

Book An Appointment

First Name

Last Name

Email Address

Phone Number

Contact

Time

Patient

Office Location

Reason for Visit

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.

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Charleston
Columbia

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candidate for dental implants

Answer The Following Questions To Learn More About Our Pricing And Financing Options.

What Best Describes Your Condition? *

I Have All My Teeth Missing One Tooth Missing Multiple Teeth Missing All My Teeth

What Best Describes Your Condition? *

I Have All My Teeth Missing One Tooth Missing Multiple Teeth Missing All My Teeth

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

Crowns and/or Bridges Partials Dentures None of Above

Have You Experienced 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 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 Cannot 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?

Very Little, Not In A Rush Moderate, 1-3 Months High, Looking For Help Now!

Have You Had Treatment Plans From Other Doctors For Dental Implants Recently? *

Yes No

Are You The Decision Maker In Regards To Your Dental & Healthcare?

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 $50-149/Month $150-$249/Month $250-349/Month Over $350/Month

Which Best Describes Your Current Credit Score?

Below 580 580-999 1000-1200 1200-1500 Over 1500

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? *

I Have All My Teeth Missing One Tooth Missing Multiple Teeth Missing All My Teeth

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

Crowns and/or Bridges Partials Dentures None of Above

Have You Experienced 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 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 Cannot 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?

Very Little, Not In A Rush Moderate, 1-3 Months High, Looking For Help Now!

Have You Had Treatment Plans From Other Doctors For Dental Implants Recently? *

Yes No

Are You The Decision Maker In Regards To Your Dental & Healthcare?

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 $50-149/Month $150-$249/Month $250-349/Month Over $350/Month

Which Best Describes Your Current Credit Score?

Below 580 580-999 1000-1200 1200-1500 Over 1500

Should you have difficulty getting approved for financing, do you have a co-signer with at least a 660 credit score that can help you?

Yes, I have a co-signer No, I don't have a co-signer I don't need a so-signer, I have credit score more than 660

What is your relationship to your co-signer?

Spouse Parent Other

Will your co-signer be able to come to the consultation appointment with you or be available by phone for 10 to 20 minutes if they cannot attend the consultation appointment?

Yes, they can No, they cannot come to the appointment or be available by the phone

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