Chicago, IL

872-233-4192

1828 W Foster Ave.

Chicago, IL 60640

309-326-7283

502 Riverside Dr.

East Peoria, IL 61611

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

Are you currently wearing dentures? *

Yes

No

What made you reach out to our office? *

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: *

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? *

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

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

What is your timeline to receive treatment? *

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? *

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? *

Fixed Full Arch

Implant Supported Denture

Single Implant

Traditional Denture

Not Sure

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

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? *

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 *

No Financing

$150-$249/Month

$250-349/Month

Over $350/Month

Payment plans are based on credit approval, you may also bring in co-signer. If you could guess, what is your credit score? *

500- 550

551 - 600

601 - 650

651 - 700

701+

I don't know my credit score

Do You Have a Co-Signer? *

Yes

No

Do You Own Your Home? *

Yes

No

Currently Paying Mortgage

Unfortunately We Do Not Accept Grants Or Medicaid, Were You Planning On Using Either Of These To Pay For Your Dental Implant Procedure? *

Yes

No

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

Do you consent to receive texts and emails regarding Dental Implant treatments and the prices associated? *

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. *

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 *

0%

I understand that by hitting "Submit" I am opting into receiving text, emails, and phone calls relating to booking a dental implant consultation. Also 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

BONUS!!

Receive A Special Promotion That Can Save You Hundreds!