Patient Information

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
Patient Information Form....
Name*

First NameLast Name
Phone Number*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
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*

PainCrown(s)Implant(s)Root CanalRoutine ExamRoutine CleaningOther
Dental History Please indicate any of the following problems:
Click for choices*

Red, swollen, bleeding gumsClicking or popping in jawBroken/Chipped ToothStained TeethRinging in earBlisters/Sores in or around mouthSensitive Teeth/GumBad BreathBroken Filling(s)Teeth GrindingNo history of dental problemsOther
MEDICAL HISTORY: Please indicate if you have or ever had any of the following:*

Heart DiseaseHeart Attack/StrokeArtificial ValvesShinglesDiabetesGlaucomaRheumatic FeverLow Blood PressureHigh Blood PressureVenereal DiseaseArtificial OrgansOther Bleeding ProblemsRespiratory ProblemsHIV/AIDSArthritis/Rheumatoid ArthritisRadiationTuberculosisLiver ProblemsHepatitis A/B/C/DCancer / TumorNo health concernsOther
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:*

NoneAspirinIbuprophenSulfaPenicillinCodeineLatexLocal AnestheticsOther:Metal/Nickel or any other metals?Other
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 plan to submit a claim to your dental insurance provider, please notify the receptionist prior to receiving treatment. Some patients choose to file their own claims independently.Should you request assistance from Amazing Dental Care in submitting your insurance claim, a non-refundable fee of $35.00 will be due at the time of your request.If you initially decline this service but later decide to submit a claim through your insurance provider, the documentation and processing fee will increase to $75.00.
Follow-Up Insurance Questions:You have indicated that you will not be seeking reimbursement from your dental insurance provider. As a result, no documentation or X-rays will be provided at the end of your treatment, other than receipts confirming payment to our clinical staff.If you choose to file an insurance claim at a later date, there will be a $75 fee for processing and providing the necessary documentation, including X-rays.Please confirm your understanding of this policy by checking the appropriate box.

I will not seek from my dental insurance provider.I would like to update my response. I will be seeking reimbursement from my dental insurance provider and agree to pay the $35.00 fee to receive the necessary documentation to support my claim for dental care reimbursement.
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 understand that Amazing Dental Care will save x-rays for insurance claims. *
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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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Credit or Debit card transactions: We will add a 5% processing fee for debit or credit card transactions. We prefer payment by Check (USA check, not USA Funds) or Cash.*
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