Shore Lake Dental

Take our prequalifying survey to determine your eligibility for financing options and make the process as affordable as possible. You also receive a voucher for $500 off treatment and Free Whitening with treatment

First Name *

Last Name

Telephone Number *

Your Email Address *

What is your Age? *

When was your last visit to a dentist? *

Have you had braces or other orthodontic treatment in the past? *

Yes

No

If Yes, at what Age?

Do you have any missing teeth or need any extractions? *

Yes

No

Have you been diagnosed with gum disease or other periodontal issues? *

Yes

No

Do your gums bleed when you brush or floss? *

Yes

No

What is your main concern with your smile? *

Do you have Dental insurance? *

Yes

No

If Yes what type of dental insurance?

Are you interested in financing options to help cover the cost of treatment? We have many financing options for all credit ranges. *

Yes

No

What is your preferred method of contact for follow-up ? *

Email

Telephone

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