Tel.:(506) 2296-5669
Fax: (506) 2296-1012
Email: baldor@
racsa.co.cr
  Clinica Baldor
Please use the contact information below to schedule an appointment or inquire more about our dental practice and services.

PHONE: 506 - 22965669 FAX: 506 - 22961012 E-MAIL: baldor@racsa.co.cr

Clinica Baldor Staff
Clinica Baldor Staff
Please complete this questionnaire and send it when you contact us by e-mail.  You can copy and paste it on your e-mail and complete it. This information is very important in order for us to consider what type of treatment can be done. You will fill a more extensive questionnaire when you arrive at the clinic.
Personal Information:
*Name:
*Address:
*Email:
Home phone: Business Phone:
Genre:
Age:
General Information::
How many days are you willing to stay in Costa Rica?:
What hotel are you going to stay at? :
Treatment you need:
Periodontal scaling
Periodontal surgery
Oral Surgery
Crowns
Bridge
Fillings 
Veneers
Implants
Complete Dentures
Partial Removable Dentures
Root Canals
TMJ, Headache Treatment
Other
Do you have bleeding in your gums when you brush or floss?:
Are you having any pain in your teeth or inside your mouth:
Have you had Periodontal treatment in the past 2 years?:
List the medications you re taking:
Do you take Bisphosphonates or medications for osteoporosis:
Do you smoke?:

Do you have diabetes?:
Do you have Rheumatoid Arthritis?:
Are you HIV positive?:
Do you have heart problems or high blood pressure?:
Have you had Cancer Treatment?:
Other Diseases?:
Comments or questions:

Security Code:
 

*Mandatory information
 
 
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For comments or information, please fill in our Infomation Request Form, or contact the clinic at:
baldor@racsa.co.cr | Tel: (506) 2296-5669 | Clinic Fax: (506) 2296-1012
© 2005 Clinica Baldor. San Jose, Costa Rica