Patient information · CID-ADM-11 · v1.0

Who We May Talk To About Your Care

Names the people we may discuss your treatment with, and how you want to be contacted.

About 5 minutesRead, sign and download from your own device

Completion

0 of 14 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.

Patient full legal name *Date of birth *Email *Phone *

Treating dentist

Dr. Jain & Dr. Gupta

Treating office *Signer full legal name *Enter the patient’s name when the patient is signing. An authorized representative must enter their own name.Relationship or authorityRequired when someone other than the patient signs.

2. What you are agreeing to

What this form does

This records who you are happy for us to speak to about your care — the person waiting for you on a surgery day, the family member who calls to ask how you are, the adult child who helps you keep track of appointments — and how you would like us to reach you.

It is a record of your preferences for talking about your care. It is NOT an authorization to release your records: sending your chart, X-rays, or reports to another person or office uses the practice's separate Dental Records Release Authorization, which has its own signature.

What the people you name can and cannot do

They CAN be told how your treatment went, when to collect you, what your post-operative instructions are, and be given appointment reminders.
They CANNOT consent to treatment on your behalf, change your treatment plan, or receive copies of your records — unless they hold legal authority to act for you and we have seen it.
Naming someone does not oblige us to discuss anything with them if you are present and would rather we did not.

Your control over this

You can change or withdraw any of it at any time, in writing or by telling us, and we will act on it going forward.
You do not have to name anyone. Leaving this blank changes nothing about your care.
In an emergency we may share what is necessary for your safety even if it is not listed here, as the law permits.

3. Your case, in your words

Person we may talk to — name, relationship, and phoneLeave blank if you would rather we spoke only to you.Second person, if you want onePerson to be updated on a surgery or sedation day, if differentHow we may contact youFor example: you may leave a detailed voicemail; text me but do not call; do not leave messages with anyone else at my number.Anyone we must NOT discuss your care with

4. Confirm, then sign

The people named above may be given information about my care as described, and I understand this does not let them consent for me or receive my records.I understand that I may change or withdraw this at any time, and that leaving it blank does not affect my care.I understand that releasing copies of my records to anyone requires the practice's separate records release form.I agree to sign this form and receive it electronically. I understand this agreement applies only to this form, and that I can complete this and any other form on paper instead — completing forms on paper does not affect my treatment, my fees, or my care in any way.I understand that I may withdraw my agreement to sign electronically at any time before I sign by simply not signing and asking the office for a paper copy, and that after signing I may ask the office for a paper copy at no charge.I understand that I need a current web browser and a device able to open and save a PDF file, that I should download and keep the PDF this form produces, and that I can ask the office to print or re-send my signed form at any time.I intend my drawn or typed signature to be my electronic signature on this form, and I am signing it myself.

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.

Completion

0 of 14 required items

Patient details
Patient-specific fields
Acknowledgments
Electronic signature

Need help? Call the office before signing. A patient form should document a conversation, not replace one.

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-11 · v1.0 · Effective 06 Sep 2026 · Next clinical review 06 Sep 2028 · Owner Sambhav (Sam) Jain, DMD, MS & Arpana Gupta, DDS, MDS