Patient Forms
Complete Your Paperwork Before Your Visit
Would you like to save time during your appointment with Dr. Rakhi Jani? We welcome you to download and complete our new patient paperwork before your first visit to our Livermore office. By filling out these forms in advance, you help make your experience as streamlined and comfortable as possible. All forms are fillable PDFs — you can complete them on your computer, save, and print, or fill them out by hand after printing.
If you need assistance or have any questions about the forms, please call us at 925-447-0440. We are happy to help.
New Patient Forms
Please complete all of the following forms before your first appointment. Click each form to download the fillable PDF.
Patient Information Form
Basic contact, emergency contact, and personal information.
Health History Form
Medical history, current medications, and health conditions.
Dental Health History Form
Previous dental treatments, concerns, and oral health habits.
Financial Policy
Payment policies, insurance information, and billing agreements.
HIPAA Disclosure Agreement
Authorization for use and disclosure of health information.
General Consent Form
Consent for examination, diagnosis, and treatment.
Notice of Privacy Practices
How we protect and use your personal health information.
Patient Instruction Sheets
The following instruction sheets are provided for your reference after specific dental procedures. Your care team will also review these instructions with you at your appointment.
- Instructions After Extraction — Post-operative care instructions following a tooth extraction.
- Instructions After Denture — Care instructions for new denture patients.
- Instructions After Arestin — Post-treatment instructions following Arestin placement for gum disease.
Bringing Your Forms to Your Appointment
After completing your forms, please bring them to your first appointment along with a valid photo ID and your dental insurance card (if applicable). If you are unable to complete the forms at home, please arrive 15 minutes early so you can fill them out in our office before your scheduled time.
All patient information is kept strictly confidential in accordance with HIPAA privacy regulations.
Ready to Schedule Your First Visit?
Contact our Livermore office to book your appointment. Call 925-447-0440 or request online.
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