Ali Shirani DDS

3725 Lone Tree Way #F, Antioch, CA 94509

925-778-1998

PATIENT INFORMATION

Date
Name
Social Security #
Cell #
Home #
Address
City
State
Zip
Sex
Age
Birthdate
Employer
Occupation
Business Address
Business Phone
Whom may we thank for referring you?
E-mail
In case of an emergency, whom should we notify?
Phone

PRIMARY INSURANCE

Person responsible for account
Birthdate
Relationship to patient
Social Security #
Address
Phone
City
State
Zip Code
Person responsible employed by
Occupation
Business address
Phone
Insurance company
Contract #
Group #
Subscriber #
Other dependents covered on plan

SECONDARY INSURANCE

Is the patient covered by additional insurance?
Subscriber Name
Relationship to patient
Social Security #
Birthdate
Address
Phone
City
State
Zip Code
Subscriber employed by
Occupation
Business address
Phone
Insurance company
Contract #
Group #
Subscriber #
Other dependents covered on plan

AUTHORIZATION

I authorize my insurance company to pay to the dentist all insurance benefits otherwise payable to me for services rendered.

I authorized the use of my signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of my benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

Payment is due in full at time of treatment unless prior arrangements have been approved.

MEDICAL HISTORY

Personal Physician's Name
Phone
Current Physical Health Is:
Are you currently in the care of a personal physician?
Please explain
Do you use tobacco in any form?
Have you had any metal rods, pins of implants?
Are you taking any prescription/over the counter drugs?
Please List
Have you ever taken phen-fen, also called redux or pondimin?
lf so,when?
Have you ever had any of the following disease or medical problems?
Abnormal Bleeding
AIDS
Alcohol/ Drug Abuse
Anemia
Arthritis
Artificial Bones/ JointsNalves
Asthma
Blood Transfusion
Cancer/ Chemotherapy
Colitis
Congenital Heart Defect
Diabetes
Difficulty Breathing
Emphysema
Epilepsy
Fainting Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack/ Surgery
Heart Murmur
Hemophilia
Fosomax/ Bisphosphonates
Hepatitis
Herpes/ Fever Blisters
High Blood Pressure
HIV
Hospitalization
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Problems
Pacemaker
Psychiatric Problems
Radiation Treatment
Rheumatic/ Scarlet Fever
Seizures
Shingles
Sickle Cell disease
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis (TB)
Ulcers
Venereal Disease
Please list any serious medical condition(s) you may have had:
Are you allergic to any of the following?
Aspirin
Codeine
Dental Anesthetics
Erythromycin
Jewelry/Metals
Latex
Penicillin
Tetracycline
Other
Please list any other medications you are allergic to:
Women
Are you taking birth control pills?
Are you pregnant?
Week #
Are you nursing?

DENTAL HISTORY

Why Have You Come To The Dentist Today?
Previous Dentist
Phone
Date Of Last Visit
Reason For Change
Current Dental Health Is:
Are you currently in pain?
Do you require antibiotics before dental treatment?
Have you ever had a problem with any previous dental work?
Do you floss daily?
Type of bristles on toothbrush?
Have you ever had gum treatment?
Do your gums ever bleed?
Have you ever had periodontal disease?
Have you ever had pain/discomfort in your jaw joint? TMJ/TMD
Do you have mobility in your teeth?
Are you sensitive to:
Are you happy with the way your smile looks?
If not, what would you change?

I have received the dental materials sheet.

Initials
Date

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the office s~aff to perform any necessary dental services that I may need during d1agnos1s and treatment, with my informed consent.

Patient/Parent Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

OFFICE USE ONLY

I verbally reviewed the medical/dental information with the patient named herein.

Initials
If not, what would you change?
Doctors Comments:

Medical History Update

Has there been any change in your health status since your last visit?
If yes, explain
Patient Initials
Date
Doctors Initials
Date
Has there been any change in your health status since your last visit?
If yes, explain
Patient Initials
Date
Doctors Initials
Date
Has there been any change in your health status since your last visit?
If yes, explain
Patient Initials
Date
Doctors Initials
Date