Thank you... Your “Sedation Dentistry” Information Kit is on its way to your email!

Want A Complimentary Sedation Dentistry Consultation?

Do you avoid going to the dentist? *

YES

Are you afraid or anxious about visiting the dentist? *

YES

What resonates with you most? (select any that apply) *

I don’t want to be aware of what’s happening

I just need a little help relaxing

My fear is specific to certain procedures or tools used

My teeth are extremely sensitive

I’m terrified of needles

I’m repulsed by the noises, smells and tastes associated with dental visits

It’s uncomfortable for me to keep my mouth open for longer periods of time

My gag reflex is overactive or very sensitive

The numbing agents that dentists use don’t work well for me

I’ve been a victim of traumatic experiences “in the chair” at the dental office *

TRUE

FALSE

PLEASE NOTE: Our office does not participate with Medicare or Medicaid Insurances.

What Dental Insurance Do You Have - other than Medicare or Medicaid? *

If payment plans were an option, is that something you would be interested in?

Yes - I’m interested in a payment plan

No – I will not need a payment plan

Payment plans are available based upon credit approval of the patient or a co-signer. Which best describes your credit?

(Very Poor) Under 500

(Poor) 501-600

(Good) 600-700

(Excellent) 700+

Based on your credit, you MAY not be approved for financing. Do you have someone with good credit history who could co-sign with you?

Yes

Although your initial consultation is free, we do expect patients to respect our time and SHOW UP for their appointment. Do your commit to showing up for your consultation at the agreed upon date and time? *

Yes, I commit to showing up for my consultation on time

No, I cannot commit to showing up on time for my consultation

First Name *

Last Name *

Address *

City *

State/Province *

Zip/Postal code *

Email *

Phone *

Dr. Moussa • Top-Rated Dentist

in Montclair, NJ

Call Today! (973) 922-9254

[email protected]

204 Claremont Ave, Montclair, NJ 07042