Tooth Replacement Self Test Landing - Revive Dental

PERSONALITY: What’s keeping you from achieving your most ideal smile? Check all that apply
- Fear, I’m scared of the dentist
- Cost, I know I can’t afford it or it’s going to be too expensive
- Embarrassed, I know I haven’t been to the dentist in a long time
- Nervous, the entire process makes me feel anxious
- Education, I don’t know what I need, I don’t know who can help me, I really need to understand what all of this dental information really means
DENTAL OPTIONS: Which description best describes your smile - check all that apply
- Currently wearing a removable denture (upper, lower, or full-mouth)
- I have missing teeth scattered around my mouth
- I have one missing tooth
- I have all of my teeth but I know they are failing or I need serious cosmetic work

Request a Dental Implant Consultation with our Dental Implant Expert

Our dental office would like to offer you an opportunity for a complimentary consultation with our doctor. Our consultations are comprehensive and will give you a full understanding of what’s needed to achieve the smile of your dreams. You will meet with our dental implant team, receive an exam, and discuss a full treatment plan with our doctor. The value of this consultation is over $1000. However, it is completely free to you. We require a card to hold the appointment, and there is a $49 “no show” fee if you fail to cancel within 24-hour notice. To continue with the appointment request, please acknowledge that you confirm and understand.
To continue with the appointment request, acknowledge that you confirm and understand:*
YES, I will show up to my scheduled appointment or provide 24-hour notice to cancel.

How would you prefer we contact you to schedule an appointment?*
- Phone Call
- Text Message
- Email
Consent to be contacted
I agree to be contacted by this practice and the Dental Implant Hotline regarding my appointment and dental implants.
By clicking this box, I authorize this organization and its affiliates to contact me by SMS text messages for appointment reminders and services offered information. I understand that message/data rates may apply under my cell phone plan. I may opt-out of receiving these communications at any time by responding STOP to the text message. I also consent to receive marketing emails from this organization and its affiliates. I understand I can revoke my consent to receive emails at any time by using the Unsubscribe link found at the bottom of every email. This agreement isn’t a condition of any purchase. Terms and Privacy Policy can be found at microsite.com/TCPAterms. You may receive up to 4 messages per month. Reply STOP to end or HELP for help.

Unlock the Secret To Your Dental Health