Are You A Candidate For

Dental Implants?

DENTAL IMPLANT EVALUATION

FREE 3D CT SCAN & CONSULTATION

Are you able and willing to travel to Fishers, Indiana? Address: 13390 Overview Drive, Fishers Indiana 46037? *

Yes

No

Which Condition Best Describes you? *

I have 1 tooth missing

I have multiple teeth missing

I'm missing all of my teeth or most of my teeth

I'm struggling with traditional dentures.

How Long Have You Been Missing Your Teeth? (The longer teeth are missing the more the jaw bone shrinks) *

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

Are You Currently Experiencing A Lack Of Confidence In Social Situations or Find Yourself Hiding Your Smile? *

Yes

No

Are You Currently Unable To Eat Certain Foods Or Have To Change The Way You Chew? *

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, 1-3 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 Interested in Learning About Our Easy Monthly Payment Plans? If So, What Dollar Range Would You Like To Pay Monthly *

Financing options are available based on your credit. Which option best describes your credit history? *

Below 620

620-700

700-750

750+

Full Name *

Email *

Phone *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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.