Elyria (440) 797-4090

1212 North Abbe Rd

Elyria, OH 44035

Westlake (440) 839-4020

24600 Detroit Rd Suite #200

Westlake, OH 44145

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

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

$50-149/Month

$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

First Name *

Last Name *

Phone *

Email *

Postal Code *

Which Location Is Most Convenient For You? *

24600 Detroit Rd Suite #200 Westlake, OH 44145

1212 North Abbe Road, Suite A Elyria, OH 44035

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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

BONUS!!

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