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.
X CBC with Differential/Platelets
X Blood Type: ABO Grouping and RHO Typing
X Comprehensive Metabolic Panel (14)
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 G6PD Blood-HBG
X Hepatitis Panel (4)
X Iron SATDS-Ferritin-Trans ferritin
X Antinuclear Antibodies Direct
X Creative Kinase, Total
Testing can be performed at any of the Life Extension Centers
Life Extension Nutrition Center5990 N Federal HwyFort Lauderdale, Fl 33308(954) 766-8144
Please consider the following symptoms, please rate ONLY the symptoms pertaining to you, on a scale of 1 to 5. Rate all symptoms you have or had in the past. If you do not have the symptom, then skip it, and go on to the next.
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:
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
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
Colitis / Ulcers / Constipation / Diarrhea / Stomach cramps / Loss of appetite / Digestive problems / Frequent bloating / Frequent heartburn / Diverticulitis
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
Acne / Rashes / Skin flushes / Rough skin / Excessive itching / Dermatitis
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