www.gonaturaldentistry.com - New Patient Form

Patient Registration
Patient Information
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Date
Name *

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Address

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Physician’s Information
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Date
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Gen. Physician Oncologist Alternative Med. (Holistic) Cardiologist Chiropractor Other
Address

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Mobile Phone Number *

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Additional info / treatments
Alternative Care doctor
Last visit

Month Day Year
Date
Address

City, State

Street Address Line 2
Office Number

Area Code Phone Number
Cardiologist
Last visit

Month Day Year
Date
Address

City, State

Street Address Line 2
Office Number

Area Code Phone Number
Endocrinologist
Last visit

Month Day Year
Date
Address

City, State

Street Address Line 2
Office Number

Area Code Phone Number
Chiropractor
Last visit

Month Day Year
Date
Address

City, State

Street Address Line 2
Office Number

Area Code Phone Number
Oncologist
Last visit

Month Day Year
Date
Address

City, State

Street Address Line 2
Office Number

Area Code Phone Number
Neurologist
Last visit

Month Day Year
Date
Address

City, State

Street Address Line 2
Office Number

Area Code Phone Number
Physical Therapist
Last visit

Month Day Year
Date
Address

City, State

Street Address Line 2
Office Number

Area Code Phone Number
Acupuncturist
Last visit

Month Day Year
Date
Address

City, State

Street Address Line 2
Office Number

Area Code Phone Number

Cancellation Policy for Dental Appointments
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.
- A failed appointment is an appointment that is cancelled/rescheduled without 48 hours’ notice or an appointment where a patient does not show up.
- A cancellation or rescheduling of an appointment prior to 48 hours or more notification will result in no charge.
- We do allow for one (1) broken appointment as a courtesy.
- Any additional failed appointments will be charged a fee of $50 for a hygiene appointment and/or $75 per hour for a doctor’s appointment.
- After three (3) failed appointments you risk being dismissed from the practice.
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
Notice of Privacy Practices Acknowledgment of Receipt
We are required by applicable federal and state law to maintain the privacy of your health information. We are also
required to give this Notice about our privacy practices, and our legal duties and your rights concerning your health
information. 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.
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Date *

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First Name Last Name
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DOB

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Sex *
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Insurance company
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Diagnosis
EMPLG Employer
Priority : Routine
Stat
Cancel of
E78.0/03.0/E83.32/E55.9/D55.0
General Laboratory Testing
X CBC with Differential/Platelets
X Blood Type: ABO Grouping and RHO Typing
X Comprehensive Metabolic Panel (14)
X Phosphprus
X CPK
X TSH,T4,T3,Reverse T3 & T3 Uptake
X Vitamin D, 25-Hydroxy
X Thyroglobulin Antibodies and Peroxidase Antibodies
X Lipid Profile-Reflective Measured LDL if TRIG ABN (CHOL, TRIG,HDL,LDL,CALC
X Uric Acid
X Homocystein
X G6PD Blood-HBG
X Hepatitis Panel (4)
X Iron SATDS-Ferritin-Trans ferritin
X Antinuclear Antibodies Direct
X Creative Kinase, Total
Other
Testing can be performed at any of the Life Extension Centers

Life Extension Nutrition Center
5990 N Federal Hwy
Fort Lauderdale, Fl 33308
(954) 766-8144

Symptoms of Mercury Poisoning
Recognized by the ADA

It is well known that mercury will store 1st in the kidney and 2nd in the liver, 3rd in the neurological tissue, 4th in the GI tract, and then in the rest of the tissues. Symptoms related to mercury are vast: however, even the AmericanDental Association (ADA) admits to the following symptoms:
- Tremor observed in fine voluntary muscle movement, such as handwriting, eventually progressing to convulsions
- Depression, fatigue, increased irritability, moodiness, nervous excitability, especially when criticized
- Inability to concentrate, loss of memory
- Insomnia or drowsiness
- Nausea and diarrhea
- Loss of appetite
- Birth defects in offspring
- Nephritis or symptoms of kidney disease
- Pneumonitis
- Swollen glands and tongue
- Ulceration of oral mucosa
- Dark pigmentation of marginal gingiva and loosening of teeth
Other documented symptoms that affect various body systems include the following:
Psychological & Behavioral

Anxiety, Emotional Instability / Apathy, Forgetfulness / Tension, Lowered intelligence / Fits of anger, Manic Depression / Difficulty making decisions / Psychological disturbances / Hallucinations, Nervousness / Nightmares Short-Term memory loss
Central Nervous System

Dizziness, Convulsions, Dim Vision / Epilepsy, Insomnia, Facial Twitches / Voices in head, Hearing difficulty / Mental Disability, Ringing in ears / Muscle paralysis, Muscle twitches / Multiple Sclerosis, Difficulty Walking / Speech Disorders, Chronic Headaches / Unexplained leg jerks / Failure of muscle coordination / Noises or sounds in head / Narrowing of field of vision / Numbness of arms and legs Tremors of hands, feet, lips / Tingling of fingers, toes, lips, or nose / Loss of ability to perform hand movement
Endocrine System

Arthritis, Diabetes, Edema / Increased Sweating / Thyroid dysfunction / Leg Cramps / Pain in joints / Decreased sexual activity / Chronic low body temperature / Frequent urination / Osteoporosis / Edema / Slow healing / Kidney stones / Cold hands and feet / Weight loss / Diabetic tendency
Digestive System

Colitis / Ulcers / Constipation / Diarrhea / Stomach cramps / Loss of appetite / Digestive problems / Frequent bloating / Frequent heartburn / Diverticulitis
Immune System

Cancer / Candia / Asthma / Sinusitis / Epstein-Barr Virus / Hodgkin’s Disease / Susceptible to flu, colds, etc. / Mononucleosis / Albicans / Swollen Glands / Leukemia / Rhinitis / Chronic fatigue / Environmental illness / Immune deficiency
Skin

Acne / Rashes / Skin flushes / Rough skin / Excessive itching / Dermatitis
Oral Cavity

Bad breath / Mouth ulcers / Loss of teeth / Increased flow of saliva / Enlarged Salivary glands / Metallic taste in mouth / Burning sensation in mouth / Periodontal (gum) disease / Sore throat-persistent cough / Bleeding gums / Leukoplakia / Swollen tongue / Bone loss around teeth
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New Patient Form

Patient Registration

Patient Information

Emergency Contact

Physician’s Information

Medical History

Cancellation Policy for Dental Appointments

Notice of Privacy Practices Acknowledgment of Receipt

Additional Medical History

Diet

Medical History

Medications / Supplements

General Laboratory Testing

Patient Symptom Survey

Allergies

Digestive problems

Cancer

Cardiovascular (Heart)

Ears

Emotional

Head

Energy/Activity

Joint / Muscle

Endocrine

Lungs

Eyes

Mind/ Brain Fog

Mouth/Throat

Skin

Neurological

Weight

Nose

Other symptoms or diagnosis

Psychiatric Diagnose

Symptoms of Mercury Poisoning