Call the Dental Implant
Co-ordinator to book your free Clinical Assessment

01608 646 620

Address

Chipping Norton Dental
Implant Centre
28 New Street
Chipping Norton
Oxfordshire
OX7 5LJ
Email Us

Opening Hours

Monday to Thursday:
8.00 am – 6.00 pm
Friday:
8.00 am – 5.00 pm

Online Implant Assessment


FREE INITIAL ONLINE DENTAL IMPLANT ASSESSMENT

TYPE "A" FOR ABSENT AND "E" FOR A TOOTH YOU THINK MAY NEED TO BE EXTRACTED

UPPER JAW

YOUR RIGHT SIDE

  • UR8
  • UR7
  • UR6
  • UR5
  • UR4
  • UR3
  • UR2
  • UR1
 

YOUR LEFT SIDE

  • UL1
  • UL2
  • UL3
  • UL4
  • UL5
  • UL6
  • UL7
  • UL8

LOWER JAW

YOUR RIGHT SIDE

  • LR8
  • LR7
  • LR6
  • LR5
  • LR4
  • LR3
  • LR2
  • LR1
 

YOUR LEFT SIDE

  • LL1
  • LL2
  • LL3
  • LL4
  • LL5
  • LL6
  • LL7
  • LL8

Please also fill in the form below, completing all fields before submitting

Name*
Address
Postcode
Telephone
Mobile*
Email*
Would you like to be contacted by?
 Telephone   Email   Letter  
Do you smoke?
 Yes   No     If yes, how many per day? 
 Cigarettes   Cigars   Pipe  
Do your gums bleed ?
 Yes    No
Do you regularly suffer from tooth infections?
 Yes   No  
How is your general health ?
 Good   Average   Poor
Do you wear dentures?
 Yes   No      If yes, for how many years?   
How old are you?
Recent tooth extraction?
  Within the past 3 months     3-6 months     6-12 months     12 months +   
Do you require finance before you proceed with implant restoration treatment?

  Yes    No
Briefly outline what problems you have with your mouth and what you hope we can achieve.

** If you have recently had an implant assessment or consultation, and would like to send us a copy of the report and/or treatment plan, then please do so. The information on a treatment plan will generally give us most of the information we require to prepare a cost estimate, which we will send within 5 working days for you to make a comparison.