(859) 904-5595

2300 Conner Road

Hebron, KY 41048

(859) 762-2511

353 Crossroads Blvd

Cold Spring, KY 41076

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? *

Missing teeth

Tooth pain

Improving appearance

Unstable dentures

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? *

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

$250-$350/Month

$350-$450/Month

Over $450/Month

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

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 *

Postal Code *

Which Location is Most Convenient? *

Hebron - 2300 Conner Road, Hebron, KY 41048

Cold Spring- 353 Crossroads Blvd, Cold Spring, KY 41076

What Is Your Preferred Language? *

English

Spanish

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

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

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