(419) 780-2810

Are you A Candidate For Dental Implants?

dental implant evaluation

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

How Long Have You Been Missing Your Teeth? *

I'm Not Missing Teeth

Less Than A Year

More Than A Year

Do You Currently Have Any Of The Following Treatments?*

Crowns and/or Bridges

Partials

Dentures

None of the Above

Have You Experienced Any Type Of Insecurities Regarding The Way Your Teeth Look? *

Yes

No

Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods? *

Yes

No

What Is The Most Important Outcome You Are Seeking?

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? *

Time

Money

Fear

Can't Find The Right Dentist

What Is your Level of Urgency To Find Relief From Any Type Of Pain Or Discomfort That You May Be Feeling? *

1 - Very Little, I'm Not In A Rush

2- Moderate, I-3 Months

3 - High, I'm Looking For Help Now!

Have You Had Treatment Plans From Other Doctors For Dental Implants Recently? *

Yes

No

Are You The Decision Maker In Regards To Your Dental & Healthcare? *

Yes

No

Which Best Describes Your Current Credit Score?

Below 580

580-699

700+

I'm Not Sure

Are You Interested in Learning About Our Easy Monthly Payment Plans? If Yes, What Dollar Range Would You Like To Pay Monthly

No Financing

$250-$349/Month

Over $350/Month

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 *

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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.

COMPLETE THIS EVALUATION TO INSTANTLY DISCOVER:

If you Are a candidate for dental implants
What treatment options are available for you
Pricing and financing options

Contact Us

(419) 780-2810

Address

19 W. Market St, Suite A

Tiffin, Ohio 44883