• (787) 844-0233
  • recepcion@dentalimplantcentersweb.com
Pre-Registration - Step 1 of 6

Register

Confirm your password
Provide your email address

Personal Info

*

Address

Emergency Contact

Employer

Primary Insurance

Secondary Insurance

Medical History

Are you allergic to or have you had any reactions to the following?

Women only

Please indicate below any medication that you are currently taking

Do you have or have you had any of the following?

Are you currently taking this type of medication, Oral bisphosphonate (e.g Fosamax,Boniva,Nerixia,Actonel,Dridonel,Fosamax-Plus D,Reclast,Binosto,Atelvia,Aclasta)

Are you currently taking any type of anticoagulant (blood thinners)

Smile Profile

Have you ever experienced any of the following problems in your jaw?

Current Oral condition

What you want to change about your oral condition?

Smile Analysis?

Dental Implant Center

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect.

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. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. 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. For more information about our privacy practices, or for additional copies of this Notice, please contact our office.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemails, emails, texts, postcards, or letters).

Initials
Date  October 16, 2018, 4:20 pm



Confirm your account2

Account

Profile

Primary Insurance

Secundary Insurance