What Best Describes Your Condition?
*
I Have All My Teeth
Missing One Tooth
Missing Multiple Teeth
Missing All My Teeth
How Long Have You Been Missing Your Teeth?
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Not Missing My Teeth
Less Than A Year
More Than A Year
Do You Currently Have Any Of The Following Treatments?*
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Crowns and/or Bridges
Partials
Dentures
None of the Above
Have You Experienced Any Type Of Insecurities Regarding The Way Your Teeth Look?
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Yes
No
Does Your Condition Have A Negative Impact On Your Ability To Eat or Chew Certain Foods?
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Yes
No
What Is The Most Important Outcome You Are Seeking?
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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?
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Time
Money
Fear
Cannot 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?
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1 - Very Little, Not In A Rush
2- Moderate, 1-3 Months
3 - High, Looking For Help Now!
Have You Had Treatment Plans From Other Doctors For Dental Implants Recently?
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Yes
No
Are You The Decision Maker In Regards To Your Dental & Healthcare?
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Yes
No
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
Which Best Describes Your Current Credit Score?
*
Below 580
580-699
700+
Not Sure
First Name
*
Last Name
*
Phone
*
Email
*
What Is Your Preferred Location?
*
Cold Springs, KY - 3760 Alexandria Pike, Cold Spring, KY 41076
Cincinnati, OH - 7655 Five Mile Rd Suite 219, Cincinnati, OH 45230
Hebron, KY - 2161 N Bend Rd Suite A, Hebron, KY 41048