Patient Information

Patient Information Form....
Please do not USPS "paper" mail this form.

Please submit on-line or print and take to the office.

Mexico address (note: mail delivery service is not available)

Ave International Y Calle 3ra Local#2 CP

Los Algodones

Baja California Norte Mexico 21970

USA mailing address

1107 S 5th Ave 217

Yuma, AZ 85364

Lead Dentist: Dr. Leobardo Rameriz, License #2964294

Owner/General Manager: Andrea Chisolm

Office Phone: 480-332-0774, option 1
Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Email
Date of Birth (01/01/1900) *
Primary Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Residential Arizona Community if this Applies
Arizona Community
Example: Leisure World
How did you hear about Amazing Dental Care? Please be specific (name of publication or community event; name of referral or sales person). *
Reason for today's Visit *

Pain Crown(s) Implant(s) Root Canal Routine Exam Routine Cleaning
Dental History Please indicate any of the following problems:
Click for choices *

Red, swollen, bleeding gums Clicking or popping in jaw Broken/Chipped Tooth Stained Teeth Ringing in ear Blisters/Sores in or around mouth Sensitive Teeth/Gum Bad Breath Broken Filling(s) Teeth Grinding No history of dental problems
MEDICAL HISTORY: Please indicate if you have or ever had any of the following: *

Heart Disease Heart Attack/Stroke Artificial Valves Shingles Diabetes Glaucoma Rheumatic Fever Low Blood Pressure High Blood Pressure Venereal Disease Artificial Organs Other Bleeding Problems Respiratory Problems HIV/AIDS Arthritis/Rheumatoid Arthritis Radiation Tuberculosis Liver Problems Hepatitis A/B/C/D Cancer / Tumor No health concerns
Do you require an antibiotic or pre-medication before your dental appointment? *

Yes, I require pre-medication (antibiotics) prior to dental treatment. No, I do not require pre-medications prior to my dental appointment. I don't Know
Please list all medications you are currently taking:
Enter Medications below. If you are on a blood thinner, your dental procedures may be delayed. Please contact your medical doctor to discuss dental treatment needed and if you should stop taking the blood thinner.
Are you allergic to: *

None Aspirin Ibuprophen Sulfa Penicillin Codeine Latex Local Anesthetics Other: Metal/Nickel or any other metals?
Payment Details
Payment: Our policy requires 50% payment at your initial appointment. Final payment is required as each procedure is completed. Most appointments require 2 days. Military or IPA patients must show their ID before your procedure begins. We cannot refund or reimburse you after your procedures are priced and started.

If you are paying with a debit/credit card, we add 5%.
WILL YOU SUBMIT TO INSURANCE PROVIDER
If you will be submitting a claim for your dental INSURANCE carrier, please inform the receptionist before completing your dental care. Some patients file their own claims. If Amazing Dental Care personnel assist you with submitting insurance claims, there will be a $25.00 non-refundable fee payable before at the time of your request.
OUR GUARANTEE:

We are proud to build a mutual relationship based on trust, and integrity, and we commit to excellence in all we do. Our goal is to work together in maintaining optimal oral health and beautiful confident smiles for all our patients.

It is our responsibility to help prevent disease, restore oral health, and educate our patients for long-term success. Our success relies on our patient's promise to commit to preventative care. This helps prevent future problems and saves you loss of function, loss of structure, as well as time and money. During your examination, our dental professionals will offer you a recommended course of treatment. The decision you make does not have to be done at the time and we will not pressure you to make a decision.

Regular professional exams, dental radiographs, and dental hygiene visits are an essential part of dental healthcare. Your individual condition depends on the frequency of those continued care visits, and the individual and personalized recommendations we make for you.

This Guarantee applies to the dental procedure you have completed at Amazing Dental Care, only. Should you encounter a problem with the dental care we have provided, our warranty requires that you return to Amazing Dental Care so we may address and correct any concern you may have with your dental plan. With the above in mind, we are very pleased to offer our active patients a 2 year treatment warranty for general dentistry.

Exceptions are listed below:
I agree that the guarantee will be invalidated if I neglect my oral hygiene. *
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I agree that the guarantee will be invalidated if I do not follow the treatment plan specified, including smoking, alcohol abuse, or drug abuse. *
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I agree that the guarantee will be invalidated if I incur damage caused by sports, third party or other accidents. *
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I agree that the guarantee will be invalidated if I have unfulfilled payment obligations to Amazing Dental Care. *
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Night Guard: A 90 day warranty is provided. We cannot offer a 2-year warranty on this apparatus as it's durability may vary depending on the severity of your teeth grinding. *
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Dentures or Partials, please plan on returning to Amazing Dental Care after you receive your permanent appliance. Dentures and Partials require additional adjustments. *
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Dental Implants: Amazing Dental Care does not guarantee or warranty dental implants. Occasionally, implants fail soon after the dental procedure or several years after a successful procedure. Some of the most common reasons for implant failure include overloading them by initially providing too few implants (to save cost, the patient may have insisted on too few implants), by placing too much stress on the implants through excessive grinding or clenching of your teeth, or due to poor dental hygiene. Again, a thorough assessment and appropriate treatment plan is essential to minimize the risk of your dental implants failing. *
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Crowns or Bridge: Occasionally, an infection or damage of the natural tooth under a crown or bridge may occur, resulting in loss of the bridge or crown we provided. Should this happen, we will not replace the crown or bridge, nor be responsible for these costs. *
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Crowns or Bridge: After your crown or bridge is placed, please do not eat or drink anything for 2 hours. *
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Crowns or Bridge: Unfortunately, since crowns are not placed on pristine teeth but instead those that have been seriously compromised by fracture, breakage or the presence of tooth decay, complications can and do occur. In some cases, it's possible that the same traumatic event that has caused the need for crown placement has also damaged or compromised the tooth's nerve tissue (pulp). If so, root canal treatment will ultimately be required. *
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PFM crowns are “thicker” than a cosmetic crown. If you chose a PFM crown, there will be a grey hue at the gum line. This is how the crown is manufactured, and is not due to a defect in material or workmanship. If adjustments are needed after the crown is placed, the metal will show. If this is unacceptable, you may want to consider a Zirconium or Porcelain Crown. Please look at the differences below and on our website. *
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Crowns or Bridge: We do not warranty or replace, at our expense, your decision to select dental work that you later find unsatisfactory due to the color, shape or size you selected. We provide patients the opportunity to choose these features during the preparation but we cannot take responsibility for your decision afterward. *
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Appointment Time: We do our best to be punctual. At times our dental care professionals fall behind schedule. This may occur for a number of reasons, particularly when patients arrive, are examined and require more extensive dental care than anticipated. Please call the office before your appointment to ask how close we are to your scheduled appointment time. The office phone number is 480-463-3202. *
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