Are you A Candidate For Dental Implants?

dental implant evaluation

What made you reach out to our office? *

Tooth Pain

Missing Teeth

Insecurities about the way you look

All of the above

What Best Describes Your Condition? *

I Have All My Teeth

I'm Missing One Tooth

I'm Missing Multiple Teeth

I'm Missing All My Teeth

Are you currently wearing dentures? *

Yes

No

What is your timeline to receive treatment? *

Very little, I'm in no rush

Moderate, Within 1-3 months

High, I need help now

How Familiar are you with the "All-On-4" treatment? Scale of 1-10 *

Have you seen another dentist about your condition? *

No, This is my first consultation

Yes, I did not feel comfortable with the other practice

Yes, I'm looking to compare pricing

If this is a second opinion what type of implant solution are you looking for? *

Dental implants contribute to your overall well-being and are worth the investment. Have you looked into the out-of-pocket expenses associated with this treatment? *

Yes

No

Given that dental implants are an elective procedure, insurance coverage may only extend to a portion of the treatment costs. Could you please share your current credit score status to better assist you? *

Do you have anyone you can bring along with you for the consultation to assist you with this investment? *

Yes

No

Please Describe your current Oral Health situation and the challenges that you are Experiencing. *

For your convenience, we will send you the customized information in regards to pricing for dental implants via text and email *

Yes send me the information

No, I do not wish to receive information regarding pricing for dental implants

By selecting no, we have no immediate way to send you the information that you are requesting. *

Yes I consent to receive this information

I would like to schedule an appointment to talk in person

I would like to speak to someone via phone call to discuss

I do not want this information

First Name *

Last Name *

Phone *

Email *

Postal Code *

Which Location Is Most Convenient For You? *

420 Main St Grafton, OH 44044

1212 Abbe Rd N STE D Elyria, OH 44035

I understand the information disclosed in this form may be subject to re-disclosure and may no longer be protected by HIPAA privacy regulations and the HITECH Act. I understand that by hitting "Submit" I am opting into receiving text, emails, and phone calls relating to booking a dental implant consultation.

COMPLETE THIS EVALUATION TO INSTANTLY DISCOVER:

If You're A Candidate For Dental Implants
What treatment options are available for you
Pricing and financing options. *Pricing is based on Credit Approval

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