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<form action="/" method="post" class="ng-pristine ng-valid"> <input type="hidden" id="sguid" name="sguid" value="a52481be-2c07-4600-a746-a2a0543c6daa">
  <div class="panel-heading">
    <h3 class="panel-title">
      <span>
        <img src="/Content/images/icon-information.png">
      </span>Patient Consent
    </h3>
  </div>
  <div class="panel-body" style="height:auto">
    <div class="col-lg-12 col-md-12 col-sm-12">
      <p> *Because of HIPAA Federal regulations protecting your privacy, we wish to inform you that we will release no information about you without your consent. We are allowed to release this information to your insurance company or as necessary to
        get paid for our services. You can have access to your records by simply asking. </p>
      <p>By agreeing with this consent form, you permit the release of any information to or from your dental practitioner as may be required.</p>
      <p>You certify that you, and/or your dependent(s), have insurance coverage as submitted on the following registration form and assign directly to your dental practitioner all insurance benefits, if any, otherwise payable to you for services
        rendered. You understand that you are financially responsible for all charges whether or not paid by insurance. You authorize the use of your signature on all insurance submissions. Your dental practitioner may use your health care
        information and may disclose such information to your Insurance Company(ies) and their agents for the purpose of obtaining payment for service and determining insurance benefits or the benefits payable for related services.</p>
    </div>
    <div class="clearfix"></div>
  </div>
  <div class="panel-footer">
    <span class=""><a href="#" class="btn btn-primary consentbtn ">Decline</a></span>
    <span class=""><input type="submit" value="Agree" class="btn consentbtn btn-default "></span>
  </div>
  <div align="center">
    <table width="135" border="0" cellpadding="2" cellspacing="0" title="Click to Verify - This site chose Symantec SSL for secure e-commerce and confidential communications.">
      <tbody>
        <tr>
          <td width="135" align="center" valign="top">
            <script type="text/javascript" src="https://seal.websecurity.norton.com/getseal?host_name=patientregistration.denticon.com&amp;size=L&amp;use_flash=YES&amp;use_transparent=YES&amp;lang=en"></script><br>
            <a href="http://www.symantec.com/ssl-certificates" target="_blank" style="color:#000000; text-decoration:none; font:bold 7px verdana,sans-serif; letter-spacing:.5px; text-align:center; margin:0px; padding:0px;">ABOUT SSL CERTIFICATES</a>
          </td>
        </tr>
      </tbody>
    </table>
  </div>
</form>

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RICCOBENE ASSOCIATES WINSTON SALEM

201 CHARLOIS BOULEVARD



WINSTON SALEM, NC 27103



WINSTONOM@BRUSHANDFLOSS.COM





PATIENT CONSENT

*Because of HIPAA Federal regulations protecting your privacy, we wish to inform
you that we will release no information about you without your consent. We are
allowed to release this information to your insurance company or as necessary to
get paid for our services. You can have access to your records by simply asking.

By agreeing with this consent form, you permit the release of any information to
or from your dental practitioner as may be required.

You certify that you, and/or your dependent(s), have insurance coverage as
submitted on the following registration form and assign directly to your dental
practitioner all insurance benefits, if any, otherwise payable to you for
services rendered. You understand that you are financially responsible for all
charges whether or not paid by insurance. You authorize the use of your
signature on all insurance submissions. Your dental practitioner may use your
health care information and may disclose such information to your Insurance
Company(ies) and their agents for the purpose of obtaining payment for service
and determining insurance benefits or the benefits payable for related services.


Decline


ABOUT SSL CERTIFICATES

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