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Root Canal Therapy
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Cleaning & Prevention

Prophylaxis (Teeth Cleaning)
Dental Exams
Deep Cleaning

Surgical Dentistry

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Surgical Placement
Dental bone graft
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New Patient Forms

1ABOUT YOU

2SPOUSE INFORMATION

3PRIMARY INSURANCE

4MEDICAL HISTORY

5FINANCIAL GUIDELINES

6ACCEPT PRIVACY

ABOUT YOU

Today's Date:(Required)

MM slash DD slash YYYY

Email Address:

Name(Required)

First Last

I Prefer To Call

nick name

DOB

MM slash DD slash YYYY

Age(Required)

Address

Street Address

Marital Status

Single

Married

Divorced

Widowed

Hm #:

Cell #:

Ext :

Employer:

Occupation

Whom may we thank for referring you?

Previous Dentist:

Last visit Date

MM slash DD slash YYYY

Spouse Information

His / Her Name:

First Last

Employer

Wk #:

Ext:

DOB:

MM slash DD slash YYYY

dl#:

PRIMARY INSURANCE

Dental Coverage?

Yes

No

Insurance Co:

Address:

Phone:

Group #:

Insured ID / SS #:

Insured`s Name:

Relation:

Insured DOB:

Insured Employer

Insured Address

SECONDARY INSURANCE

Dental Coverage?

Yes

No

Insurance Co:

Address:

Phone:

Group #:

Insured ID / SS #:

Insured`s Name:

Relation:

Insured DOB:

MM slash DD slash YYYY

Insured Address

Insured Employer

EMERGENCY CONTACT

Name

Name Relation

Cell #:

Hm #:

Address :

Medical History

Do You Have a Primary Care Physician?

Yes

No

Primary Care Physician Name

BP#:

Your Current Physical Health is

Good

Fair

Poor

Do your Smoke or use tobacco in any other from?

Yes

No

Have you had any metal rods, pain or implants?

Yes

No

Are you nursing?

Yes

No

Are you taking any prescription / over the counter medication?

Yes

No

Please list each:

Have you ever taken fasamax or any biophosphonate?

Yes

No

For Women: Are you using birth control?

Yes

No

Are you pregnant?

Yes

No

Week #

Abnormal Bleeding

Yes

No

HIV

Yes

No

Alcohol / Drug abuse

Yes

No

Kideny Problems

Yes

No

Anemia

Yes

No

Liver disease

Yes

No

Arthritis

Yes

No

Artificial joints / valves

Yes

No

Low Blood Pressure

Yes

No

High Blood Pressure

Yes

No

Lupus

Yes

No

Blood transfusion

Yes

No

Mitral Valve Prolapse

Yes

No

Cancer / chemotherapy

Yes

No

Osteoporosis

Yes

No

Colitios

Yes

No

Pacemaker

Yes

No

Congenitial heart defect

Yes

No

Pyschiatric Problems

Yes

No

Diabetes

Yes

No

Radiation Treatment

Yes

No

Diffficulty Breathing

Yes

No

Rheumatic fever

Yes

No

Emphysema

Yes

No

Shingles

Yes

No

Epilepsy / seizures

Yes

No

Sickle Cell Disease

Yes

No

Fainting Spells

Yes

No

Sinus Problems

Yes

No

Frequent Headaches

Yes

No

Stroke

Yes

No

Heart Attack

Yes

No

Thyroid Problems

Yes

No

Hemophilia

Yes

No

Tuberculosis

Yes

No

Hepatitis

Yes

No

Ulcers

Yes

No

Herpes / Fever Blisters

Yes

No

Veneral Disease

Yes

No

Are you on any medications?

Yes

No

Medication

Why have you come to the dentist today:

Do you require antibiotics before dental treatment?

Yes

No

Are you currently in pain?

Yes

No

Have you had a serious or difficult problem associated with previous dental treatment?

Yes

No

Do you have fears about going to the dentist?

Yes

No

Have you ever had gum treatment?

Yes

No

Do you now or have you ever experienced pain / discomfort in your jaw? (TMJ/TMD) ?

Yes

No

Do you like your smile?

Yes

No

Would you like to improve your smile?

Yes

No

Do your gums ever bleed?

Yes

No

Have you ever had any oral surgery?

Yes

No

When did you do your surgery?

How many time a week do you floss?

How many time a week do you brush?

Type of Bristles?

Soft

Medium

Hard

How long do you use a toothbrush before replacing it?

Are your teeth sensitive to heat, cold or anything else?

I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the dental office to the group of insurance otherwise payable to me. I understand that I am responsible for all costs of dental treatment regardless of estimated coverage from my insurrance company. I hereby authorize releae of ay information including the diagnosis and record of treatment or x-rays rendered, to my insurance company.(Required)

I agree with all the rules mentioned(Required)

I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.
I hereby authorize payment directly to the dental office to the group of insurance otherwise payable to me.
I understand that I am responsible for all costs of dental treatment regardless of estimated coverage from my insurrance company.
I hereby authorize releae of ay information including the diagnosis and record of treatment or x-rays rendered, to my insurance company.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Payment is due in full at the time of treatment

I understand that i am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the dental office to the group of insurance otherwise payable to me. I understand that I am responsible for all costs of dental treatment regardless of estimated coverage from my insurrance company. I hereby authorize releae of ay information including the diagnosis and record of treatment or x-rays rendered, to my insurance company.(Required)

I agree with all the rules mentioned(Required)

I understand that i am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.
I hereby authorize payment directly to the dental office to the group of insurance otherwise payable to me.
I understand that I am responsible for all costs of dental treatment regardless of estimated coverage from my insurrance company.
I hereby authorize releae of ay information including the diagnosis and record of treatment or x-rays rendered, to my insurance company.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Financial Guidelines

please read and intial each line

I understand that if I have no dental insurance, payment is due in full as services are rendered. Our office accepts cash, check, and credit card.

I authorize payment of dental benefits to Dr.Hosseini and any release of my dental information necessary to process my dental claims.

I understand that even though I may have some type of insurance coverage, I am fully responsible for the payment of services rendered by Dr.Hosseini and or her staff through her direction. It is my responsibility to contact my insurance company to solve any payment discrepancies, I understand that authorization from my insurance company is not a guarantee of payment. Monitoring my insurance maximum is my responsibility. Services provided in other offices deplete my insurance maximum, which is my responsibility. Services provided in other offices deplete my insurance maximum, and I am responsible for advising the office of these services.

Every new patient must have his or her insurance card presented to the reception during the initial visit, If the patient has no insurance card, he/she must provide complete dental insurance information and eligibility will be verified. otherwise, the patient will be required to pay the full cost of the visit.

Our office does not accept any DMO / HMO at this time, if a patient who has DMO / HMO insurance wishes to be seen by Dr.Hosseini, full payment of the cost of treatment is required.

I understand that Dr.Hosseini may not be a preferred provider for my dental plan. if I choose to have services rendered by this office, I may still use my insurance, but there may be a difference in insurance benefits. It is my responsibility to determine if this office is a preferred provider for my dental insurance.

All estimated co-payments must be made at the time of service. if the deductible has not been met, this must be satisfied as well. I understand that having dual dental insurance coverage does not guarantee 100% payment by the two insurance companies as some companies have a non-duplication of benefits clause.

If a balance is left on an account over 90 days, the account could be turned over for collection unless payment arrangements are made with the office in advance. if my account is turned over for collection, I understand that it would result in my immediate dismissal from practice.

Our office requires three business days’ notice for all scheduling changes. if more than two scheduling changes are made without proper notification, a refundable $ 50-100 reservation fee will be required to make future appointments. If a scheduling change is made on a reserved appointment without proper notification, the fee will not be refunded.

Signature(Required)

Date(Required)

MM slash DD slash YYYY

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I,

, have received a copy of this office’s Notice of privacy practices.

Your name

{ Please print your name }

Signature

Date

MM slash DD slash YYYY

Contact Us

(925) 682-3223
(925) 682-3274
info@bddentalservices.com
2991 Treat Blvd. Suite C Concord, CA 94518

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