www.gonaturaldentistry.com - New Patient Form

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Date *

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Name *

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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
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Additional info / treatments
Alternative Care doctor
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Date
Address

City, State

Street Address Line 2
Office Number

Area Code Phone Number
Cardiologist
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Date
Address

City, State

Street Address Line 2
Office Number

Area Code Phone Number
Endocrinologist
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Date
Address

City, State

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Office Number

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Chiropractor
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Date
Address

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Office Number

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Oncologist
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Date
Address

City, State

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Office Number

Area Code Phone Number
Neurologist
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Date
Address

City, State

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Office Number

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Physical Therapist
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Date
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Acupuncturist
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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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