Nagib Bahri D.D.S., M.A.G.D

168 North Euclid Avenue, Upland, CA, 91786

909-982-8893

Patient Information

Please complete the following confidential information

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out these forms completely. The better we communicate, the better we can serve you.

Personal information

A. PATIENT:

Name:
Today’s Date
Birthdate
Preferred Nickname?
Age
Address:
Zip Code
H. Phone
Cell
Other Phone Numbers:
E-mail Address
Social Security No
Driver License No
Occupation
Employer
Business Address
Business Phone
Ext.
If minor, please give name of parent or legal guardian:
Referred by
Person to contact in case of emergency
Phone

B. SPOUSE

Name
Social Security No
Driver License No
Occupation
Employer
Business Address
Business Phone
Ext.

Account information

A. RESPONSIBLE PARTY:(if different from patient)

Name
Relationship to Patient
DOB
Address
Zip Code
Phone Number
Ext.
Business Address
Social Security No
Driver License No

B. PRIMARY DENTAL INSURANCE

Name of Insured
Date of Birth of Insured
SSN or Ins. ID
Relationship to Patient
Employer
Insurance Co

C. SECONDARY DENTAL INSURANCE

Name of Insured
Date of Birth of Insured
SSN or Ins. ID
Relationship to Patient
Employer
Insurance Co

Terms and Conditions:

As a condition of treatment by this office, I understand financial arrangements must be made in advance. All emergency dental services, or any services performed without prior financial arrangement, must be paid for in cash at the time of service.

I understand that dental services rendered are charged directly to me and that I am personally responsible for payment for all dental services performed.

If I carry insurance, I understand that this office will help prepare forms to assist in making collections from insurance companies and will credit such collections to my account.

I authorize the dental office to release any information, including the diagnosis and records of any dental treatment rendered, to third party payers or other health care practitioners.

I authorize my insurance company to pay directly to the dental office for any exam or treatment rendered to my dependents or me from benefits accruing to me under my dental policy.

I understand that my dental insurance carrier may pay less than the actual estimate given to me for the services rendered. My benefits are based purely on a contract between my insurance company and myself. I agree to be responsible for full payment on all services rendered to my dependents or me.

I authorize this dental office to call or text me on my home, work or cell phone to discuss relevant treatment, account and insurance information. I can withdraw my consent anytime.

A photocopy of this form shall be considered as effective and valid as the original.

I have read the above conditions and agree to their content.

Signature:

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Date

Health Questionnaire

These questions are for your benefit and assure that treatment will take into consideration your past and present health status.
Some questions may seem unrelated to your dental condition, but they are all associated with proper oral health care.

I- MEDICAL HISTORY

Are you in good health?
Date of last physical examination
Are you now under the care of a physician?
If so what is the condition being treated?
Have you ever had any serious illness or operation?
If so, what illness or operation?
Have you ever been hospitalized?
If so, what was the problem?
Are you taking any medicine, or herbal supplements?
Any recreational drugs?
If so, what?
Have you before, or are you now taking any medications for bone density?
Have you ever been pre-medicated with antibiotics prior to your dental treatment?
Are you sensitive or allergic to any drugs?
If other, what drugs?

Do you have or have you had any of the following: (Please Check any known conditions):

Do you have any disease, condition or problem not listed that you think we should know about?
If so, what is it?
Do you smoke? If so, how much per day?

Women:

Are you pregnant?
If so, what is it?
Do you take Birth Control Pills?

II- DENTAL HISTORY

Do your gums ever bleed when brushing or flossing?
Are your teeth sensitive to Hot / Cold / Sweets / Biting?
Do you have an unpleasant taste / Bad Breath?
Have you ever had local anesthetic (Lidocaine, Carbocaine, etc.) ?
Have you ever had any unfavorable reaction from a local anesthetic?
Have you had any serious trouble associated with any previous dental treatment?
If so, what?
Does dental treatment make you nervous?
 
How long since your last dental treatment?
Have you had any periodontal treatment?
Are you happy with your smile?
If there was an easy and fast way to whiten your teeth, would you want it?

To the best of my knowledge, all of the preceding information is correct and true. If I have any changes in my health or medications, I will promptly inform the doctor at my following appointment.

Signature

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Date:
BP
Pulse