Referral Page | Made Dental Implant & Prosthodontics Center

Get an Implant Consultation

For more information or to schedule an appointment, call us at (219) 258-7076 or complete the form.

See if you're a candidate for dental implants and request a free consultation by completing this short questionnaire online.

1 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

Please ensure you select at least one option

2 How Long Have You Been Missing Your Teeth?*

I'm not missing teeth

Less than a year

More than a year

Please ensure you select at least one option

3 Do You Currently Have Any Of The Following Treatments?*

Crowns and/ or Bridges

Partials

Dentures

None of the above

Please ensure you select at least one option

4 Have You Experienced Any Type Of Insecurities Regarding The Way Your Teeth Look?*

Yes

Please ensure you select at least one option

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

Yes

Please ensure you select at least one option

6 What Is The Most Important Factor That Has Prevented You From Getting Treatment?*

Time

Money

Fear

Can't find the right dentist

Please ensure you select at least one option

7 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, 1-3 months

3 - High, I'm looking for help now

Please ensure you select at least one option

8 Have You Had Treatment Plans From Other Doctors For Dental Implants Recently?*

Yes

Please ensure you select at least one option

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

Yes

Please ensure you select at least one option

10 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

Please ensure you select at least one option

11 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

Please ensure you select at least one option

12 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

Please ensure you select at least one option

13 When is the best time to contact you?

Morning

Afternoon

Evening

Please ensure you select at least one option

14 Thank you for the information. For a free consultation and to complete your submission, provide us with your contact information.*

First name*

Please enter first name

Last name*

Please enter last name

Phone number

Please enter phone number Please enter valid phone

Email*

Please enter email address Please enter valid email

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