Patient Registration Form

Patient Registration Form

Thank you for taking the time to fill out this form! We welcome you to our great family of friends and patients. You are now on your way to having the healthy teeth and an attractive smile you want and deserve.

Patient Information

First Name
Middle Name
Last Name
SS #
Home Phone
Driver's License
Your email address
How long
Marital Status
Name of Spouse
Spouse Number
Emergency Contact Person #1
How did you hear about our office
Who was your previous dentist?
What did you like about him/her?
What did you dislike about him/her?

Person Responsible For Payment

(Disregard if same as above)

Relationship to Patient
Driver's License
SS #
Length of Employment
Employer's Address

Dental Insurance Information

Insured Name
Insured DOB
Insured SSN
Relationship to Insured (Primary)
Relationship to Insured (Secondary)
Insurance Company
Insurance Company Address
Insurance Company #
Group or Policy #

I agree to have my signature considered to be "on file" for purposes of insurance form processing. I also agree to be responsible for payment for any service or portion of service not covered by insurance. I authorize release of necessary information relating to the processing of dental insurance forms. In order for us to process your insurance forms more rapidly and to assist you in getting all the benefits to which you are entitled, please sign and date below.

I request that all dental benefits, if any, or other amounts otherwise payable to me or on my behalf for services rendered, be paid directly to the provider of service. I understand that I am financially responsible for all charges for services performed by provider. If insurance proceeds are insufficient to cover my obligations for services rendered, I am liable for the shortfall. I authorize the provider of service to release all information necessary to secure the payment of benefits. I also consent to the examination and/or treatment of myself and all minor children listed by doctors, doctors' assistants and other medical personnel. Failure to provide complete information may result in my receiving a bill for services.

Signature of Patient OR Responsible Party

Dental History

Why have you come to the dentist today?
Have you seen another dentist for your dental needs?
How would you describe the condition of your teeth and gums?
Are you currently in pain or discomfort with your teeth or gums?
The date of your last dental visit
Previous dentist's name
If you could wave a magic wand, and change anything you could about the appearance of your smile, what would you like to do?
If you could easily and safely whiten your teeth, would you be interested?
How often do you brush your teeth?
Floss your teeth?
Do your gums bleed when you brush?
When flossing?
Are your teeth sensitive to
Have you ever experienced pain in your jaw joint?
Do you grind your teeth?
Have you ever been treated for TMJ symptoms?

Medical History

Have you ever had, or been treated for any of the following diseases or medical problems?

Abnormal Bleeding




Drug/Alcohol Abuse

High Blood Pressure

Low Blood Pressure


Rheumatic Fever



Kidney Problems

Artificial Heart Valve

Heart Attack/Stroke

Psychiatric Problems

Artificial Hip/Joint

Heart Murmur



Heart Surgery


Damaged heart valves



Coronary Occlusion


Coronary Insufficiency

Respiratory Problems

Sexually Transmitted Disease


Have you been treated for any other illness?


Do you need to be pre-medicated before dental treatment?

Are you allergic or have you reacted adversely to any of the following?





Dental Anesthetics

Sulfa Drugs




Codeine or other narcotics

Phen Phen

Are you allergic to any other medication?


What prescription medication(s) are you currently taking?



Are you taking birth control pills?

Are you pregnant?

If yes, how many months?

Are you nursing?

I confirm as true the above health information. I hereby authorize the dentist to take x-rays, study models, photographs or any aids deemed appropriate by the dentist in charge of may care to make a thorough diagnosis of my (or the patient's) dental needs. I also authorize the dentist to perform any and all forms of treatment, medication, and therapy that may be indicated.

Signature of Patient or Responsible Party


Have you been any changes in your medical history, including any medications that you take, since you last completed this form?

Please Read Carefully

Because we care so much about you and value you as our patient, we have compromised a NEW office policy regarding missed appointments and canceled appointments.

This new policy has become a necessity and will affect all patients. It would be a disservice to you if we did not emphasize the importance of your own commitment to your dental care.

Your commitment to yourself and to us is to KEEP YOUR SCHEDULED APPOINTMENT. As always we will make every effort to accommodate your scheduling needs and keep our schedule "on time". In return, we ask that you help us by keeping your scheduled appointments and by notifying us 48 HOURS IN ADVANCE IF YOU ARE UNABLE TO DO SO.

Consider your appointment with Dr. Amari as your personal reservation. And, as with all reservations you make (such as airline or hotel), there must be a cancelation policy.


  1. As a courtesy to you, we will make every effort to confirm your reserved appointment. But, please do not consider it our responsibility to do so. If our attempts are unsuccessful, it is still your responsibility to keep your reserved appointment or contact us 48 hours in advance to change or cancel the reserved time.

  2. All patients who fail to arrive for their reserved appointments or who cancel without 48 hours advance notice will be charged a $50.00 missed appointment fee. Please note that this missed appointment fee is NOT covered by any insurance plans and is your responsibility to pay. Fee shall be waived only for unforeseen circumstances at Dr. Amiri's discretion.

  3. If missed appointments become repeated, any future appointments will require a credit card number to be kept on file and used immediately for a missed appointment fee.

In keeping with our high standards of dentistry, we prefer to accommodate all of our patients with longer, comfortable appointments. We know with busy and hectic lifestyles, this is what most patients prefer. In doing so, a one hour reserved appointment that is missed or canceled late can upset an entire schedule.

We appreciate all of our patients and it is not our intent to offend anyone. With your compliance, we will be more able to keep our schedule "on time", accommodate any emergencies and help patients on our waiting list. We thank you for your understanding in this matter.

Patient Signature


Patient Acknowledgement Of The Notice Of Privacy Practices And Consent For Use And Disclosure Of Personal Health Information

Patient Name


Signature of Patient or Parent or Legal Guardian

acknowledge that I have either received a copy of this office's NOTICE OF PRIVACY PRACTICES or that this office's NOTICE OF PRIVACY PRACTICES was made available to me to receive.

Signature of Patient or Parent or Legal Guardian

consent to the use and disclosure of my personal health information by your office for Treatment, Billing/Payment and Healthcare Operations as outlined in the NOTICE OF PRIVACY PRACTICES.

Informed Consent General Dentistry

All patients complete 1 thru 4 below, and 5 thru 13 as needed.

I understand that the initial visit may require radiographs in order to complete the examination, diagnosis, and treatment plan. I understand I am to have work done as detailed in the attached treatment plan.

I have been informed and understand that antibiotics and analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reactions). I have informed the Dentist of any know allergies. They may cause drowsiness, lack of awareness, and coordination which can be increased by the use of alcohol or other drugs. I understand and fully agree not to operate any vehicle or hazardous device for at least 12 hours or until fully recovered from the effects of the anesthetic, medication, and drugs that may have been given me in the office for my care. I understand that failure to take medications prescribed for me in the manner prescribed may offer risks of continued or aggravated infection and pain and potential resistance to effective treatment of my condition. I understand that antibiotics can reduce the effectiveness of oral contraceptives (birth control pills). I understand that all medications have the potential for accompanying risks, side effects, and drug interactions. Therefore, it is critical that I tell my dentist of all medications I am currently taking.

I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during the examination, the most common being root canal therapy following routine restorative procedures. I give my permission to the Dentist to make any/all changes and additions as necessary.

I understand that popping, clicking, locking and pain can intensify or develop in the joints of the lower jaw (near the ear) subsequent to routine dental treatment wherein the mouth is held in the open position. Although symptoms of TMD associated with dental treatment are usually transitory in nature and well tolerated by most patients. I understand that should the need for treatment arise, then I will be referred to a specialist for treatment, the cost of which is my responsibility.

I understand the treatment is preventive in nature, intended for patients with healthy gums, and is limited to the removal of plaque and calculus from the tooth structures in the absence of periodontal (gum) disease.

I understand that a more extensive restoration than originally diagnosed may be required to additional decay or unsupported tooth structure found during preparation. This may lead to other measures necessary to restore the tooth to normal function. This may include root canal, crown, or both. I understand that care must be exercised in chewing on fillings during the first 24 hours to avoid breakage. I understand that sensitivity is a common after-effect of a newly placed filling.

Alternatives to removal have been explained to me (root canal therapy, crown, and periodontal surgery, etc.) and I authorize the Dentist to remove the following teeth.

and any others necessary for reasons in paragraph #3. I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of which are pain, swelling, the spread of infection, dry socket, exposed sinuses, loss of feeling in my teeth, lips, tongue, and surrounding tissue (Parasthesia) that can last for an indefinite period of time or fractured jaw. I understand bleeding could last for several hours. Should it persist, particularly if it's severe in nature, it should receive attention and this office must be contacted. I understand that I may need further treatment by a specialist or even hospitalization if complications arise during or following treatment, the cost of which is my responsibility.

a. I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily, and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. I realize that the final opportunity to make changes in my new crown, bridge, or veneer (including shape, fit, size, and color) will be before cementation. It has been explained to me that in a very few cases, cosmetic procedures may result in the need for future root canal treatment, which cannot always be predicted or anticipated. I understand that cosmetic procedures may affect tooth surfaces and may require modification of daily cleaning procedures. It is also my responsibility to return for permanent cementation within 20 days after tooth preparation. Excessive delays may allow for decay, tooth movement, gum disease, and/or bite problems. This may necessitate a remake of the crown, bridge, or veneer. I understand there will be additional charges for remakes or other treatment due to my delaying permanent cementation.

b. I am electing to use noble, high noble or ceramic instead of base metal in my crown and bridge restorations.

c. I am electing to do a fixed bridge or implant replacement of missing teeth instead of a removable appliance. I understand that this fixed bridge or implant and crown may not be a covered benefit under my insurance policy.

I realize that full or partial dentures are artificial, constructed of plastic, metal, and/or porcelain. The problems of wearing those appliances have been explained to me including looseness, soreness, and possible breakage. I realize the final opportunity to make changes in my new denture (including shape, fit, size, placement, and color) will be the "teeth in wax" try-in visit. Immediate dentures (placement of dentures immediately after extractions) may be uncomfortable at first. Immediate dentures may require several adjustments and relines. A permanent reline or a second set of dentures will be necessary later. This is not included in the initial denture fee. I understand that most dentures require relining approximately three to twelve months after initial placement. The cost for this procedure is not included in the initial denture fee. I understand that it is my responsibility to return for delivery of dentures. I understand that failure to keep delivery appointments may result in poorly fitted dentures. If a remake is required due to my delay of more than 30 days, there will be additional charges.

I realize there is no guarantee that root canal treatment will save my tooth, that complications can occur from the treatment, and that occasionally, canal material may extend through the root tip which does not necessarily affect the success of the treatment. The tooth may be sensitive during treatment and even remain tender for a time after treatment. Hard to detect root fracture is one of the main reasons root canal fail. Since teeth with root canals are more brittle than other teeth, a crown is necessary to strengthen and preserve the tooth. I understand that endodontic files and reamers are very fine instruments and stresses can cause them to separate during use. I understand that occasionally additional surgical procedures may be necessary following root canal treatment (Apicoectomy). I understand that the tooth may be lost in spite of all efforts to save it.

I understand that I have a serious condition causing gum inflammation and/or bone loss and that it can lead to the loss of my teeth and/or negative systemic conditions (including uncontrolled diabetes, heart disease, and pre-term labor, etc). Alternative treatment plans have been explained to me, including non-surgical therapy, antibiotic/antimicrobial treatment, gum surgery, and/or extractions. I understand the success of any treatment depends in part on my efforts to brush and floss daily, receove regular therapeutic cleanings as directed, follow a healthy diet, avoid tobacco products and follow other recommendations. I understand bleeding could last for several hours. Should it persist, particularly if it is severe in nature, it should receive attention and this office must be contacted. I understand that periodontal disease may have a future adverse effect on the long-term success of dental restoration work.

I understand that no dentistry is permanent and that ideal implant placement may not be possible based on anatomic limitations. I have been informed that there is always the possibility of failure resulting from the tissues of the body not physiologically accepting these artificial devices, and infections may occur postoperatively which may necessitate the removal of the affected implant(s). I realize there is the slight possibility of injury to the nerves of the face and tissues of the oral cavity, and this numbness may be of a temporary or, rarely, permanent in nature. I understand that it is absolutely necessary with implant therapy to have regular periodic examinations and cleanings. I agree to assume the responsibility to make appointments and report as instructed by the treating dentist.

Bleaching is a procedure done either in-office (approximately 1 hour) or with take-home trays (several treatments over 2-4 weeks). The degree of whitening varies with the individual. The average patient achieves considerable change (1-3 shades on the dental shade guide). Coffee, tea, and tobacco will stain teeth after treatment and are to be avoided for at least 24 hours after treatment. I understand I may experience sensitivity of the teeth and/or gum inflammation, which may subside when treatment is discontinued. The Dentist may prescribe fluoride treatments to aid with sensitivity. Carbamide peroxide and other peroxide solutions used in teeth bleaching are approved by the FDA as mouth antiseptics. Their use as bleaching agents has unknown risks. Acceptance of treatment means acceptance of risk. Pregnant women are advised to consult with their physician before starting treatment.

I elect to have nitrous oxide in conjunction with my dental treatment. I have been informed and understand the possible side effects that may occur. These include, but are not limited to, nausea, vomiting, dizziness, and headache. I understand that nitrous oxide use is not indicated if I am pregnant.

I understand that my insurance may provide only a minimum standard of care. I understand that submitting insurance and receiving a benefit is my responsibility. I elect to follow the Dentist's recommendation of optimal dental treatment.

I understand that dentistry is not an exact science and that therefore reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment I have requested and authorized. I understand that each Dentist is an individual practitioner and is individually responsible for the dental care rendered to me. I also understand that no other Dentist or corporate entity, other that the treating Dentist, is responsible for my dental treatment. I acknowledge the receipt of and understand post-operative instructions and have been given an appointment date to return.






8105 Edgewater Dr. Suite 124,
Oakland, CA 94621

Phone:  (510) 924-7310

Office Hours

MON - TUE9:00 am - 6:00 pm

WED10:00 am - 7:00 pm

THU9:00 am - 6:00 pm

FRI9:00 am - 5:00 pm

SAT8:00 am - 3:00 pm