Dr. Marzieh Karkhanehchi ORTHODONTIST
Dr. Logesh Swayamprakasam DDS MPH MS
8105 Edgewater Drive, Suite #1
Oakland, CA 94621
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Dr. Zaid Faraji DDS
Dr. Juan Luque DDS
Dr. Madhavi Setty DDS

PATIENT INFORMATION

LAST
FIRST
MI
PREFERRED TITLE
PARENT/GUARDIAN NAME(S)
SCHOOL/LOCATION
ADDRESS LINE 1
ADDRESS LINE 2
CITY
ST
ZIP CODE

EMERGENCY INFORMATION

In case of emergency, please provide information for the nearest relative or designated contact person not at the patient’s address:

NAME
RELATIONSHIP

EMPLOYMENT INFORMATION

ADDRESS LINE 1
ADDRESS LINE 2
CITY
ST
ZIP CODE

INSURANCE INFORMATION

LAST
FIRST
MI
CITY
ST
ZIP CODE
CITY
ST
ZIP CODE

DENTAL HISTORY

CHILD/MINOR PATIENTS: PLEASE ANSWER THE FOLLOWING QUESTIONS:

PRIMARY PHYSICIAN INFORMATION

MEDICAL HISTORY

ALL PATIENTS: DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):

ALL PATIENTS: ARE YOU ALLERGIC TO OR HAVE YOU EVER HAD ANY REACTION TO THE FOLLOWING? (CHECK ALL THAT APPLY):

MEDICATION INFORMATION

ALL PATIENTS: ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):

Oakland Dental Specialty Center 8105 Edgewater Drive, Suite #1 Oakland, CA 94621 (p) 510-256-7116 info@oaklanddentalspecialties.com