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

What Is The Most Important Outcome You Are Seeking? *

Function - Eating, Chewing, Talking

Aesthetics - Beautiful, Natural Looking Teeth

Option 3Both 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?

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

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

Which Practice Location do you perfer?

11258 Illinois Rte 59 Unit #1, Naperville, IL 60564

16240 Louis Ave, South Holland, IL 60473

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 *

Email *

Phone *

Postal code *

I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (XXX) XXX-XXXX for assistance. You can reply STOP to unsubscribe at any time.