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Patient information · CID-ADM-06 · v1.0

Confidential Health History

Medical and dental history used to plan safe implant, surgical, restorative, and sedation care.

About 12 minutesRead, sign and download from your own device

Completion

0%

0 of 23 required items

  • Patient details
  • Patient-specific fields
  • Acknowledgments
  • Electronic signature

Before you sign

Review this document before your appointment when possible. Your treating dentist must still explain the patient-specific treatment, benefits, material risks, alternatives—including no treatment—and answer your questions. Do not sign after receiving sedating medication.

1. Who this form is for

Fields marked * are required for a signed PDF.

Treating dentist

Dr. Jain & Dr. Gupta

2. What you are agreeing to

Why we ask

Medical conditions, medicines, allergies, prior surgeries, tobacco use, and pregnancy status can change dental treatment, healing, prescribing, and sedation safety. Complete answers help the clinical team coordinate care and reduce avoidable risk.

3. Your case, in your words

Do you take a blood thinner or have a bleeding disorder?
Have you taken bisphosphonate, denosumab, antiresorptive, or antiangiogenic medicine?
Are you pregnant, possibly pregnant, nursing, or trying to conceive?

4. Confirm, then sign

Patient or authorized representative signature *

Sign inside the box using a mouse, stylus, or finger.

Where this form goes

Nothing you type here is uploaded — the signed PDF is built in your browser. Download the signed PDF saves it to your device and sends nothing. Bring it to your appointment or hand it to the front desk, and staff will place it in your dental record.

Who is responsible for this document

Responsible clinicians

  • Dr. Sambhav (Sam) Jain, DMD, MS

    Lead Implant Dentist & Founder · CA Dental License #50472

  • Dr. Arpana Gupta, DDS, MDS

    Implant Dentist · CA Dental License #50467

Arpana Gupta, DDS and Sambhav Jain, DDS, Inc., practicing as Center for Implant Dentistry.

Where to reach us

  • Fremont

    3381 Walnut Ave, Fremont, CA 94538
    Phone (510) 574-0496 · Fax (510) 574-0499

  • San Francisco

    4318 Geary Blvd, Suite 201, San Francisco, CA 94118
    Phone (415) 696-2922 · Fax (510) 574-0499

Questions about a form? info@bayareaimplantdentistry.com — that address is for questions about a form, not for sending one. A completed form holds health details that should never travel through ordinary email: download the signed PDF and bring it to your appointment, or hand it to the front desk.

What happens to what you type

While you type, nothing is sent and no draft, analytics, or advertising script records your answers. Download builds the PDF in your browser, saves it to your device, and sends nothing — this website never transmits your completed form. Hand it to our staff at your visit so they can place it in your record. Once accepted there, it becomes part of your dental record and is protected under California’s Confidentiality of Medical Information Act (Civil Code § 56) and, where it applies, HIPAA. You can read how we handle records in our health information privacy notice.

Controlled document CID-ADM-06 · v1.0 · Effective 31 Jul 2026 · Next clinical review 31 Jul 2028 · Owner Sambhav (Sam) Jain, DMD, MS & Arpana Gupta, DDS, MDS