Mina Narula DDS, MDS 71949 Hwy 111 Suite 200, Rancho Mirage, California, 92270 760-340-2026
Mina Narula DDS, MDS
71949 Hwy 111 Suite 200, Rancho Mirage, California, 92270
760-340-2026
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In accordance with HIPPA regulations, I hereby give my permission for the office of Dr. Mina Narula to use patient records and information for diagnosis, treatment planning, promotion, education, and insurance purposes.
I authorize the dentist to release any information including the diagnosis, and records for treatment rendered to me or my child if necessary for insurance purposes. I also authorize direct payment of insurance benefits to the dentist for services rendered when indicated.
I understand that where approriate, credit bureau reports may be obtained.
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Patients often request changes in their bite or face and relief from pain or discomfort. Please help us understand your problem by checking the following information. Please be specific (check the words backward, less, shorter, etc.)
Teeth: If your teeth could be changed, how would you like them to change?
Face: If your facial appearance could be changed, what would you change?
Symptoms: If you want to reduce pain or discomfort, where would it be located? Please be specific about the location; check the right side, left side, or both if they apply.