Although we primarily treat the area in and around your mouth, we know that your mouth is a part of your entire body. Existing health problems that you may have, or current medications that you may be taking, could have an important interrelationship with the treatments you will receive. We thank you for answering the following questions accurately.
I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by Dr. Yolanda Cintron to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all the charges whether or not paid by insurance. I understand that I will be responsible for any collection costs and attorney fees if I fail to honor my financial obligation for my dental treatment. I authorize Dr. Yolanda Cintron to use any image or video recording of me to diagnose, develop a treatment plan, for patient viewing / education and any form of marketing. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in address, insurance info and medical status. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.
Our goal at International Center For Dental Excellence is to provide quality dental care in a timely manner. We do understand that illness, emergencies, flat tires, and bad weather do occur. We ask our patients to give us 48 hours’ notice whenever possible if they cannot keep an appointment. This allows us time to fill our schedule with other patients who may be waiting. We appreciate your understanding and consideration regarding our cancellation and failed appointment policy.
To cancel appointments please call 954-938-4599 Opt. 1. If you do not reach the scheduling coordinator you may leave a detailed message on the voice mail or with our after-hours answering service. You may also cancel your appointment using the confirmation e-mail that is sent to you from International Center For Dental Excellence through our patient communication system, RevenueWell. - Info@drcintron.com
We are required by applicable federal and state law to maintain the privacy of your health information. We are alsorequired to give this Notice about our privacy practices, and our legal duties and your rights concerning your healthinformation. We must follow the privacy practices that are described in the Notice while it is in effect. This notice takes effect immediately and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request. You may request a copy of our notice at any time.
Access and Authorization for Use and/or Disclosure of Protected Health Information
I authorize Dr. Yolanda Cintron DMD, PA to release confidential health information including but not limited to X-rays, photos, clinical findings, treatment notes , lab reports, medical histories, medications and other by email, phone, fax, and mail. I am giving permission to discuss post op instructions with your chosen responsible party that will be picking you up when you are sedated.