www.gonaturaldentistry.com - Patient Registration

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.
Patient Signature *

Clear
Patient Name *

First Name Last Name
Date *

Month Day Year
Date

Medical Records Release Form
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.
Physician Information
Name *

First Name Middle Name Last Name
Address *

Street City State Zip

Street Address Line 2
Office Number
Email *
example@example.com
Fax Number
*

I understand that the protected health information specified below may include mental health, substance abuse (e.g., drugs, alcohol) HIV/AIDS status information, diagnostic and treatment records. I have read and understand the following statements:
*

I am the patient and/or legal guardian and I understand and agree to the provisions of this form/authorization
Name *

First Name Middle Name Last Name
Address

Street City State Zip

Street Address Line 2
Home Phone Number *

Area Code Phone Number
Mobile Number

Area Code Phone Number
Other Numbers
Patient’s Signature *

Clear
Patient’s Name *

First Name Last Name
Date *

Month Day Year
Date
Should be Empty:

Patient Registration

Patient Information

Emergency Contact

Physician’s Information

Medical History

Cancellation Policy for Dental Appointments

Notice of Privacy Practices Acknowledgment of Receipt

Medical Records Release Form

Physician Information