Find Out If You're A

Candidate For Dental Implants

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

Our practices are located in Maineville, OH and Cincinnati, OH. Are you willing to travel to one of our locations? *

Yes

No

What made you reach out to our office? *

Tooth Pain

Missing Teeth

Insecurities about the way you look

All of the above

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

Are you currently wearing dentures? *

Yes

No

What is your timeline to receive treatment? *

Very little, I'm in no rush

Moderate, Within 1-3 months

High, I need help now

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

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? *

Dental implants contribute to your overall well-being and are worth the investment. Have you looked into the out-of-pocket expenses associated with this treatment? *

Yes

No

Given that dental implants are an elective procedure, insurance coverage may only extend to a portion of the treatment costs. Could you please share your current credit score status to better assist you? *

Do you have anyone you can bring along with you for the consultation to assist you with this investment? *

Yes

No

Please Describe your current Oral Health situation and the challenges that you are Experiencing. *

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? *

Maineville 6270 Rivers Bend Dr, Maineville, OH 45039

Kemper 315 W Kemper Rd, Cincinnati, OH 45246

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.