What Best Describes Your Condition?
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I Have All My Teeth
I'm Missing One Tooth
I'm Missing Multiple Teeth
I'm Missing All My Teeth
How Long Have You Been Missing Your Teeth?
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I'm Not Missing Teeth
Less Than A Year
More Than A Year
Are you currently wearing dentures?
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Yes
No
What made you reach out to our office?
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Tooth Pain
Missing Teeth
Insecurities about the way you look
All of the above
Select All That Apply - Do You Feel That Tooth Loss Has Affected Your:
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Personal Life
Professional Life
Enjoyment of Food
Physical Comfort
Oral Health
Appearance/Self Confidence
Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods?
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Yes
No
What Is The Most Important Outcome You Are Seeking?
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Function - Eating, Chewing, Talking
Aesthetics - Beautiful, Natural Looking Teeth
Both Are Equally As Important
What Is The Most Important Factor That Has Prevented You From Getting Treatment?
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Time
Money
Fear
Can't Find The Right Dentist
Please Describe your current Oral Health situation and the challenges that you are Experiencing.
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What is your timeline to receive treatment?
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Very little, I'm in no rush
Moderate, Within 1-3 months
High, I need help now
Have you seen another dentist about your condition?
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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?
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Fixed Full Arch
Implant Supported Denture
Single Implant
Traditional Denture
Not Sure
Are You The Decision Maker In Regards To Your Dental & Healthcare?
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Yes
No
Most Dental Implant procedures are not covered by insurance. However we offer many payment plans that make it quite affordable and offer low monthly rates. Are you interested in a payment plan?
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Yes I am!
No I will not need a payment plan
Are You Interested in Learning About Our Easy Monthly Payment Plans? If So, What Dollar Range Would You Like To Pay Monthly
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No Financing
$50-149/Month
$150-$249/Month
$250-349/Month
Over $350/Month
How Familiar are you with the "All-On-4" treatment? Scale of 1-10
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Do you consent to receive texts and emails regarding Dental Implant treatments and the prices associated?
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Yes send me the information
No, I do not wish to receive information regarding pricing for dental implants
By selecting no, we want to make sure that you are aware that we will not be able to provide you with the pricing and information you have requested regarding Dental Implants, immediately. We will reach out via a phone call but if you would like an email and text regarding pricing, please opt-in below.
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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
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Last Name
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Phone
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Email
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Postal Code
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Our practice is located in Troy, IL. Are you willing to travel to this location?
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Yes
No