URBN Dental - Website Contact Form

1
How Many Missing Or Broken Teeth Do You Have?* This field is required.
All
6+
4-5
3 or less
2
What Is Your Age?* This field is required.
60+
50-59
40-49
<40
3
Do You Currently Have Any of These Dental Solutions?* This field is required.
Denture or Partial Denture
Bridge/Crown
Dental Implant
None of the Above
4
How Long Have You Been Missing Your Teeth? (The Longer Teeth Are Missing the More the Jaw Bone Shrinks)* This field is required.
I Still Have Them
1-6 Months
7-12 Months
1+ Years
5
Are You Currently Trying To Find Relief From Any Kind Of Pain Or Discomfort?* This field is required.
Yes
No
6
Have You Had A Dental Implant Consultation With Another Dentist?* This field is required.
Yes
No
7
How Ready Do You Feel To Do Something About Your Situation?* This field is required.
Somewhat Ready
Very Ready
I Need Something Fast
8
Do You Currently Have Blue Cross Blue Shield Medical PPO or FEP Coverage?* This field is required.
Yes
No
9
Dental Implant Procedures May Not Be Covered by Insurance. However, Many Affordable Payment Plans Are Available. Are You Interested in a Payment Plan Option?* This field is required.
Yes. I'm interested in affordable payment plan options
No. I've been saving for this type of procedure and will not need a payment plan
10
Dental Implant Costs Vary Widely. On Average, They Range From $3,100 to $5,800 but Full Mouth Implants Can Cost $21,000 to $54,000 or More. Payment Plans Start at $300/mo. Would You Like to See if You Qualify for a Payment Plan, or Continue Without?* This field is required.
Yes, please let me know if I qualify for a payment plan
No, I don't need a payment plan
11
Payment Plans Are Available Based on the Patient's or a Co-signer's Credit Approval. Which Best Describes Your Credit?* This field is required.
(Poor) Under 660
(Fair) 660-699
(Good) 700-739
(Excellent) 740+
12
I authorize URBN Dental and its affiliates to obtain a soft credit report from a consumer reporting agency to evaluate my eligibility for financing options related to dental treatment. I understand this inquiry will not impact my FICO score, is intended only for use by URBN Dental and its affiliates and its financing partners, and is kept confidential in accordance with HIPAA, Texas privacy laws, and federal consumer protection laws. By checking "I agree", I release URBN Dental and its affiliates from any liability arising from this soft credit check.* This field is required.
I agree
13
First Name* This field is required.
14
Last Name* This field is required.
15
Email* This field is required.
16
Address* This field is required.
17
Phone* This field is required.
18
Preferred Location* This field is required.
Please Select
Please Select
Uptown
Midtown
Montrose
CityCentre
Heights
Katy
Spring Branch
East River
Tanglewood
Meyerland
West University
19
Have you scheduled an appointment with us before?* This field is required.
Please Select
Please Select
Yes - I am an existing patient.
No - I am a new patient.
20
What is Your Preferred Time for Us to Contact You?* This field is required.
Morning 8 AM - 11 AM
Noon 12 PM - 1 PM
Afternoon 1 PM - 5 PM
21
What is Your Preferred Method of Contact?
Email
Phone
Text
22
By submitting this form, you agree to be contacted by phone, email or text and that any associated call may be recorded for quality and training purposes. This form and any subsequent emails or text messages should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.
23
By submitting this form, you agree to be contacted by phone, email or text and that any associated call may be recorded for quality and training purposes. This form and any subsequent emails or text messages should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.
24
liine new
25
Get Page URL
26
Get Page URL (Salesforce)
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