Angeles Health International
Dental Quote Builder

IMPORTANT:PLEASE READ

 

Your information is held in the strictest confidence. Your personal information will never be sold for marketing purposes, and will only be used to contact you in matters strictly related to your medical travel experience.

It is essential this form be filled out completely in order for the medical treatment team to properly assess your suitability for the procedure you are inquiring about. Incomplete information may result in delays in setting up necessary medical consults or finalizing your quote. Please be as thorough as possible in describing your relevant medical history, indications, diagnoses, and medications.
We take the privacy of your information very seriously; we use only HIPAA-compliant systems and processes in the accessibility, transfer and review of your medical records. Checking the boxes below indicates your understanding that:

 

Your information is held in the strictest confidence. Your personal information will never be sold for marketing purposes, and will only be used to contact you in matters strictly related to your medical travel experience.


I agree to my personal medical profile being reviewed by Angeles Health International for completeness before securely transmitting it to the surgeon for evaluation.


I am a:   Patient Case Manager
First Name:*  
Middle Initial:
Last Name:*
Email:*
Date of Birth:
Gender:
Occupation:
Last 4 Digits of Social Security Number**:
**Required for compliant record collection on patient’s behalf.
 
Street Address:*
City:*
State/Province:*
ZIP/Postcode:*
Country:
Home Phone:*
Business Phone:
Mobile Phone:

If you've been working with an Angeles Health International Case Manager, please let us know so that we can notifiy him or her when your profile has been submitted.

Which case manager have you been working with?
Would you like to be contacted in English or Spanish? English Spanish
Location Desired, if any:
Do you have a formal diagnosis or treatment plan? Yes No
Details:
 

Have you had any X-rays taken within the last year Yes No

If Yes, please provide contact information for your dentist:
First and Last Name
Specialty
Address
City
State/Province
Fax
Phone
What is your chief complaint?
What is your budget and if the full recommended treatment plan does not fall within this budget, what is your priority?
Some conditions make certain procedures dangerous and/or not possible. Please indicate if you have any of the following:
Hypertension: Yes No
Medication:
High Blood Pressure: Yes No
Medication:
Diabetes: Yes No
Medication:
Heart Condition(s): Yes No
Sjourgens Disease:
Swelling in the mouth: Yes No
Bleeding when brushing: Yes No
Are you taking any blood thinners? Yes No
Blood thinner(s) taken
Do you have any allergies, including previous reactions to anesthesia? Yes No

Do you have any excessive bleeding tendencies or problems with wounds healing? YesNo

Please Explain:
Detail all other medical conditions:
Do you have any allergies, including previous reactions to anesthesia? Yes No
Please list all allergies:
Have you ever taken a biophosphonate drug (actonel, fosamax, boniva)? Yes No
Proposed Procedure Date:
Have you ever taken a biophosphonate drug (actonel, fosamax, boniva)?

Please tell us more about your dental needs, using the below mouth diagram and the corresponding numbered tooth chart below the mouth diagram.

We have filled in a few cells as examples of the information you might include. Please note that teeth 1,16,17 and 32 are wisdom teeth, which you may have had removed.

Tooth # Concern (missing, broken, loose, discolored) Explanation of Needs (crown, veneer, root canal, etc.)

1(wisdom)
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16 (wisdom)
17 (wisdom)
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 (wisdom)