Patient's Name:(required)

Email Address:(required)

Date: (required)

SS/HIC/Patient's ID#: (required)

Home phone:(required)

Work phone:(required)

Cell phone:(required)

Address:(required)

city:(required)

State:(required)

Zip:(required)

Sex:(required)
MaleFemale

Age:(required)

Birthdate:(required)

Relationship Status:(required)
 Married Widowed Single Minor Seperated Divorced Partnered for______ years

If your answer was partner, how many years have you been together?

Occupation:(required)

Patient Employer/school:(required)

Employer/School Address:(required)

Spouse's work phone:

Spouse's Name:

Spouse's Birthdate:

Spouse's Employer:

Who is responsible for this account?(required)

Relationship to patient:(required)

Insurance company(required)

Group #(required)

Assignment and release:
I certify that I, and/or my dependent(s), have insurance coverage with the abovenamed insurance company(ies) and assign directly to Dr. David S. Nikfarjam all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named dentist may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Patient, Parent, Guardian or Personal Representative's signature(required)

Patient, Parent, Guardian or Personal Representative's name and his/her relationship(Separate the answers with a comma please)(required)

Date signed(required)

Emergency Contact Information(Specify someone who does not live in your household.)(required)

Name:(required)

Relationship:(required)

Home phone:(required)

Work phone:(required)

Reason why the person is in need of a visit:(required)

Former Dentist?:(required)

Date of last dental visit:(required)

Date of last dental x-rays(required)

City:(required)

State:(required)

How often do you floss?

How often do you brush?

Select Yes or No to indicate if you or the patient have had any of the following:

Bad breath
 yes no

Bleeding gums
 yes no

Blisters on lips or mouth
 yes no

Burning sensation on tongue
 yes no

Chewing on one side of the mouth
 yes no

Cigarette, pipe, or cigar smoking
 yes no

Clicking or popping jaw
 yes no

Dry mouth
 yes no

Fingernail biting
 yes no

Food collections between the teeth
 yes no

Foreign objects
 yes no

Grinding teeth
 yes no

Gums swollen or tender
 yes no

Jaw pain or tiredness
 yes no

Lip or cheek biting
 yes no

Loose teeth or broken fillings
 yes no

Mouth breathing
 yes no

Mouth pain,brushing
 yes no

Orthodontic treatment
 yes no

Pain around ear
 yes no

Periodontal treatment
 yes no

Sensitivity to cold
 yes no

Sensitivity to heat
 yes no

Sensitivity to sweets
 yes no

Sensitivity when biting
 yes no

Sores or growths in your mouth
 yes no

Physician's Name:

Date of Last Visit:

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionim, Adipex, Fastin(brand names of phentermine), Pondimin(fenfluramine) and Redux(dexfenfuramine)
 yes no

Select "Yes" or "No" to indicate if you have had any of the following:

AIDS/HIV
 yes no

Anemia
 yes no

Arthritis, Rheumatism
 yes no

Artificial Heart Valves
 yes no

Artifical Joints
 yes no

Asthma
 yes no

Back Problems
 yes no

Bleeding abnormally, with extractions or surgery
 yes no

Blood Disease
 yes no

Cancer
 yes no

Chemical Dependency
 yes no

Chemotherapy
 yes no

Circulatory Problems
 yes no

Congenital Heart Lesions
 yes no

Cortisone Treatments
 yes no

Cough, persistent or bloody
 yes no

Diabetes
 yes no

Emphysema
 yes no

Do you wear Contact lenses
 yes no

Epilepsy
 yes no

Fainting or dizziness
 yes no

Glaucoma
 yes no

Headaches
 yes no

Heart Murmur
 yes no

Hepatits______
 yes no

If your answer was yes to the previous question which type is it?

Herpes
 yes no

High Blood Pressure
 yes no

Jaundice
 yes no

Jaw Pain
 yes no

Kidney Disease
 yes no

Liver Disease
 yes no

Low Blood Pressure
 yes no

Mitral Valve Prolapse
 yes no

Nervous Problems
 yes no

Pacemaker
 yes no

Psychiatric Care
 yes no

Radiation Treatment
 yes no

Respiratory Disease
 yes no

Rheumatic Fever
 yes no

Scarlet Fever
 yes no

Shortness of Breath
 yes no

Sinus Trouble
 yes no

Skin Rash
 yes no

Special Diet
 yes no

Stroke
 yes no

Swollen Feet or Ankles
 yes no

Swollen Neck Glands
 yes no

Thyroid Problems
 yes no

Tonsillitis
 yes no

Tuberculosis
 yes no

Tumor/growth on head/neck
 yes no

Ulcer
 yes no

Venereal Disease
 yes no

Weight Loss,unexplained
 yes no

For Women specifically

Are you pregnant?
 yes no

Taking birth control pills?
 yes no

(If Pregnant) Due Date:

Are you nursing
 yes no

List any medications you are currently taking and correlating diagnosis:

Pharmacy number

Phone number

Check next to allergies you might have
 Aspirin Barbiturates(Sleeping pills) Codeine Iodine Latex Local Anesthetic Penicillin Sulfa Other:

If selected other what might the allergies be?