Patient Information UPDATE *** FOR OFFICE USE***

DATE Patient’s Initial DATE Patient’s Initial

Rahmat Nassi DDS 9025 Wilshire Blvd., Suite #415 Prosthodontics, Cosmetic & Implant Dentistry Beverly Hills, CA (310) 278-1771

Patient Information

Patient’s Name (Last, Fist) Date of Birth (Month, Day, Year)

Address City, State, Zip

Home Phone Cell

Work Phone E-mail

SS# Marital Status: Single □ Married □ Spouse’s Name

Emergency Contact Relation Emergency Phone

Employer Employer’s Address

City, State, Zip Do you have dental insurance? Yes □ No □

Insurance Carrier’s Name Phone

Insurance Carrier Address, City, State, Zip

Subscriber’s Name Subscriber’s Date of Birth

Subscriber’s SSN # ID # Group #

HOW DID YOU HEAR ABOUT US?

NAME, SIGNATURE DATE

MEDICAL HISTORY UPDATE *** FOR OFFICE USE***

DATE Patient’s Initial DATE Patient’s Initial

Rahmat Nassi DDS 9025 Wilshire Blvd., Suite #415 Prosthodontics, Cosmetic & Implant Dentistry Beverly Hills, CA (310) 278-1771

Medical & Dental History

In order for us to provide you with the safest and best possible care, please complete this form. All information is kept strictly confidential.

Have you ever been under the care of a Medical Doctor? PLEASE WRITE NAME & PHONE NUMBER Yes □ No □

Have you taken any prescription drugs during last 6 months? PLEASE LIST Yes □ No □

Are you taking any over the counter or herbal supplement? PLEASE LIST Yes □ No □

Have you had any surgeries and or hospitalization within the last 2 years? PLEASE LIST Yes □ No □

Are you allergic to any medication? PLEASE LIST Yes □ No □

Have you ever been told to take antibiotics prior to dental treatment? PLEASE LIST Yes □ No □

CHECK ANY OF THE FOLLOWING WHICH YOU HAVE AT THE PRESENT OR HAVE HAD IN THE PAST:

□ HEART DISEASE □ HEART ATTACK □ CHEST PAIN □ RHEUMATIC FEVER □ HEART FAILURE

□ ARTIFICIAL HEART VALVE □ HEART PACEMAKER □ STROKE □ EPILEPSY/SEIZURES □ HIVES/SKIN RASH □ ANEMIA □ LIVER DISEASE □ HEPATITIS A B C □ KIDNEY DISEASE/FAILURE □ ULCERS

□ ASTHMA □ SINUS TROUBLE □ LOW BLOOD PRESSURE □ HIGH BLOOD PRESSURE □ ACID REFLUX □ ALLERGIES □ HEMOPHILIA □ LIVER DISEASE □ PERSISTENT COUGH □ COLD SORES

□ DIABETES TYPE I OR II □ THYROID DISEASE □ ANXIETY □ EATING DISORDER □ HAY FEVER □ HIV/AIDS □ CHEMO THERAPY □ RADIATION TREATMENT □ LUKEMIA □ ARTHRITIS

□ TUBERCULOSIS □ SLEEP APNEA □ FAINTING/DIZZINESS □ SEXUALLY TRANSMITTED DISEASE

□ JOINT/KNEE REPLACEMENT

Have you ever taken any medication for Osteoporosis? Yes □ No □ Have you ever taken FEN-PHEN/ REDUX? Yes □ No □

MEDICAL HISTORY UPDATE *** FOR OFFICE USE***

DATE Patient’s Initial DATE Patient’s Initial

Rahmat Nassi DDS 9025 Wilshire Blvd., Suite #415 Prosthodontics, Cosmetic & Implant Dentistry Beverly Hills, CA (310) 278-1771

Medical & Dental History

Do you bruise easily? Yes □ No □ Have you ever had extensive bleeding? Yes □ No □ Have you ever needed a blood transfusion? Yes □ No □ Do you have or had any disease, condition or medical problem not listed above? PLEASE LIST Yes □ No □

WOMEN ONLY Are you pregnant? Yes □ No □ Are you nursing? Yes □ No□

Are you taking birth control pills? Yes □ No □ Are you planning to become pregnant? Yes □ No□

Name of your dentist: Dr. Work Phone

Address City, State, Zip

When was your last dental visit? Last dental X-rays?

What was completed during your last dental visit?

HAVE YOU EVER EXPERIECED ANY OF THE FOLLOWINGS:

Clicking or popping of jaw? Yes □ No □ Clench or grind your teeth? Yes □ No □ Pain in the jaw joint area near the ear? Yes □ No □ Hard time opening wide? Yes □ No □ Tired jaws, especially in the morning? Yes □ No □ Frequent headaches? Yes □ No □

Sore muscles in the neck or Shoulders? Yes □ No □ Gum bleeding? Yes □ No □ What kind of dental aid do you use on a regular basis? PLEASE SELECT

Regular tooth brush □ Electric tooth brush □ Dental Floss □ Mouth rinse □ What is your main chief of complaint now?

I AFFIRM THAT THE INFORMATION I HAVE GIVEN IS CORRECT TO THE BEST OF MY KNOWLEDEGE, AND THAT IS MY RESPONSIBILITY TO INFORM THIS OFFICE OF ANY CHANGES IN MY MEDICAL STATUS. NAME, SIGNATURE DATE

HIPPA UPDATE *** FOR OFFICE USE***

DATE Patient’s Initial DATE Patient’s Initial

Rahmat Nassi DDS 9025 Wilshire Blvd., Suite #415 Prosthodontics, Cosmetic & Implant Dentistry Beverly Hills, CA (310) 278-1771

HIPPA Consent Form

I, , understand that as part of my dental care, Dr. Rahmat Nassi DDS

originates and maintains health records describing my health and dental history, symptoms, examination, diagnosis,

treatment and any plans for future care or treatment. I understand that this information serves as:

• A basis for planning my dental care and treatment

• A means of communication among the other health professionals who may contribute to my health and dental care

• A source of information for applying my diagnosis and surgical information to my bill

• A means by which a third-party payer can verify that services billed were actually provided

• A tool for routine health and dental care operations such as assessing quality and reviewing the competence of

healthcare professionals

I have been informed and provided with the chance to review and obtain a copy of Notice of Privacy Practices that

contains a more complete description of information uses and disclosures, and that I have the right to review the notice

prior to signing this consent. I understand that Dr. Rahmat Nassi DDS reserves the right to change their notice of Privacy

Practices and prior to implementation will mail a copy of any revised notice to the address I’ve provided if requested. I

understand that I have the right to object to the use of my health information for directory purposes. I understand that I

have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment,

payment, or healthcare operations and that Dr. Rahmat Nassi DDS is not required by law to agree to the restrictions

requested.

I understand that I may revoke this consent in writing, except to the extent that Dr. Rahmat Nassi DDS has already take

action in reliance thereon.

Signed this day of 20

Print Patient Name

Signature

Relationship to Patient

Financial Agreement UPDATE *** FOR OFFICE USE***

DATE Patient’s Initial DATE Patient’s Initial

Rahmat Nassi DDS 9025 Wilshire Blvd., Suite #415 Prosthodontics, Cosmetic & Implant Dentistry Beverly Hills, CA (310) 278-1771

Financial Agreement

This agreement is to inform you of your financial obligations to our practice. We are committed to provide you with the

highest quality dental care. We will evaluate the state of your oral health, discuss our findings with you, give you all

potential treatment options that pertain to your condition, and provide you with an estimate of the cost. It is for you to

determine what treatment option suits your situation the best.

PLEASE READ AND INITIAL

Payment is due at time of service. (Initial_________ )

Your dental insurance is a contract between you, your employer, and the insurance company. The responsibility

of payment ultimately lies with you, the patient, not the insurance company. (Initial_________ )

As a courtesy, we will file your claim on your behalf and accept assignment of benefits. (Initial_________ )

Patients with insurance will be expected to pay their “Estimated Patient Portion” and any deductible at the time

of my visit. (Initial_________ )

Any outstanding balance will be billed to the patient and is due immediately. (Initial_________ )

We require a 48-HOUR advance notice to reschedule appointment to avoid any charges. (Initial_________ )

PAYMET OPTIONS

We accept Cash, Personal Check, and all major Credit Cards.

Outside Patient Financing is available through upon approval.

NAME, SIGNATURE DATE