Roger N. Gilbert, DDS, Inc.25875 Barton Road, Suite 104Loma Linda, CA 92354
To Change or Cancel an AppointmentWe ask that you please notify us at least 48 hours in advance to change orcancel an appointment or a $50 charge will be assessed to your account.
Acknowledgement of Receipt of HIPAA Notice of Privacy Practices
We at Roger N. Gilbert DDS Inc. are required by federal law to maintain the privacy and provide individuals with a Notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to the Notice, please ask to speak with either of our HIPPA Compliance Officers in person or by phone. If you would like a copy, please let our front desk know.
understand the aforementioned information and have received or declined a copy of Roger N. Gilbert DDS Inc.’s HIPPA Notice of Privacy Practices.
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking, could have an important interrelationship with the dentistry you receive. Thank you for answering the following questions.
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 medical status.