Patient Forms

We invite you to complete your patient forms online! This will streamline your appointment with Dr. Amirhassan Pouradib and save you time in our office. If you have any questions or want to schedule your consultation with our experienced dentist in San Rafael, California, please contact our office at 415-479-1840.






    Abnormal Bleeding / HemophilaAIDSAlcohol / Drug abuseAnemiaAnginaArthritisArtificial bones / Joints / ValvesAsthmaBlood diseaseArtificial bones / Joints / ValvesChemotherapyChicken poxCerebral palsyCongenital heart diseaseDiabetesCongenital heart defectEmphysemaEpilepsy / seizuresDrug addictionFrequent headachesGlaucomaFainting spells / seizuresFrequent headachesGlaucomaHead injuriesHerpes / Fever blistersHigh blood pressureHepatitis / jaundiceHerpes / Fever blistersKidney diseaseLive diseaseJoint replacementMitral valve prolapseNervous disorderLupusRadiation treatmentRespiratoryPsychiatric treatmentRadiation treatmentRespiratoryPsychiatric treatmentSickle cell disease / TraitsSinus problemsShinglesThyroid problemsTonsillitisStrokeThyroid problemsTonsillitisTumors or growthsUlcersVenereal diseaseAllergies or HivesArtificial prosthesisBlood transfusionColitisDifficulty breathingExcessive bleedingHay feverHeart murmurHospitalized for any reasonLow blood pressurePacemakerRheumatic / Scarlet feverSinus TroubleTuberculosisX-Ray or cobalt treatment



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