(773) 985-2539

1030 W Higgins, Suite 260

Park Ridge, IL 60068

Find Out If You're A

Candidate For Dental Implants

Answer The Following Questions To Learn More About Our Pricing And Financing Options.

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

Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods? *

Yes

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

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

Yes

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

$350 - $449/Month

Over $450/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

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 *

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.