Coastal Jaw surgery Dental Implant Quiz Step 1 of 3 33% What is your zip code?* What is your biggest dental challenge? (Select all that apply)* I am missing a single tooth I am missing multiple teeth I am struggling with my traditional dentures Most of my teeth are broken, decayed or missing How long have you been struggling with this?**Select OneLess Than 1 MonthLess Than Six MonthsLess Than 1 YearMore Than 1 yearWhat has kept you from fixing your smile? (Select all that apply)* Nothing! I am ready right now. Cost of dental procedures Fear of dental procedures Time involved in dental procedures Have not found a dentist that I am comfortable with yet If it was affordable, how soon would you be ready to move forward with treatment?*Select OneIn the next 30 daysIn the next 6 monthsI am in no rush, just researching options How do you plan to pay for your dental implant treatment? (Select all that apply)* Cash Credit Card Dental Insurance (please note: Medicare / Medicaid not accepted) Healthcare Financing (CareCredit, GreenSky) I would like to learn more about financing options / payment plans Select the option that best describes your situation.*Select OneI can afford monthly payments of $150 - $399 and have money to put downI have a set amount of cash that I can spend and need help finding a treatment plan that fits my budgetI am prepared to pay for my entire treatment up frontI do not currently have any money to afford treatmentHave you spoken to another dentist about treatment?*Select OneYes, I would like a second opinion.No, This will be my first consultation.What was the price range of the other dentist’s treatment plan?*Select One$500.00 - $2,000.00$2,000.00 - $5,000.00$5,000.00 - $10,000.00$10,000.00 - $20,000.00$20,000.00 - $30,000.00more than $30,000.00What is most important to you about your implant dentist? (select all that apply)* Lowest cost Experience placing implants Delivers highest quality Financing options Gentle and Caring How did you hear about us?* Internet Search Facebook - Instagram Referral from another doctor Print Ad Billboard Are You Ready To Take The First Step To Change Your Life And Schedule Your FREE Consultation?*Select OneYesNoName* First Last Email* Phone*Which one of our offices is most convenient for you?* Same Day Teeth® at Pikos Institute - 8740 Mitchell Blvd New Port Richey, FL 34655 Coastal Jaw at Palm Harbor - 2711 Tampa Rd. Palm Harbor, FL 34684 Coastal Jaw Surgery at Trinity - 8845 Hawbuck St Trinity, FL 34655 Coastal Jaw Surgery at Spring Hill - 4372 Commercial Way Spring Hill, FL 34606 Coastal Jaw Surgery at Tampa - 11940 Sheldon Rd Tampa, FL 33626 Pinellas Periodontics & Implant Dentistry at Clearwater - 3003 Enterprise Rd E, Clearwater, FL 33759 78423
