• "Dr. Alikhani is dedicated and a perfectionist when it comes to teeth. I am happy with her ..."

  • "It may sound weird, but I do enjoy coming to see Dr. Alikhani. She is the most gentle dent..."

  • "Very friendly staff, always willing to work with you and around your schedule. The doctor ..."

  • "Dr. Fariba was so amazing and gentle that when she was working on my teeth, she literally ..."

  • "Excellent care year after year. You really can relax in Dr. Fariba Alikhani's chair. "

  • "I am Dr. Alikhani's patient for the past 7.5 years and my experience has been outstanding ..."

  • "En el tratamiento de mis dientes, me gusta como la doctora me ha limpiado mis dientes, ha ..."

  • "I have been a patient of Dr. Alikhani for several years now and highly recommend her. She..."

  • "Our family which is composed of myself and two daughters age nine and fourteen have been c..."

  • "...I am very happy having Dr. Alikhani as my dentist and I highly recommend her your denti..."

  • "My experience in the dentist office has been excellent, the work on my teeth has been very..."

  • "Dentists are hard to come by. Some are not sensitive to your needs or don't show a concern..."

  • "I love coming her because Fariba and the staff take good care of me. "

  • "Friendly staff, excellent service. Dr. Alikhani is a real professional."

  • "The Dentist is the best. I love her thoroughness & especially her being a perfectionist. ..."

  • "Dr. Alikhani and her staff have always been professional, friendly and skilled. I trust Dr..."

  • "I've been a patient for the past few years and have been happy with Dr. Alikhani's work. I..."

View Testimonials

Contact Us 408-247-3400
1580 Winchester Blvd. # 105, Campbell, CA 95008

Patient Treatments
Preventive Treatments
Cosmetic Dentistry
Dental Implant
Crown and Bridges
Root Canal
Tx of Gum Disease
Dentures
Night Guard
Cancer Screening
Teeth Whitening
Emergencies
All Services

New Patient Form

  • Help us get to know you!

  • First Name: *

  • Last Name: *

  • Name of person whom is insured if different than patient:

  • DOB of Primary Insurance Holder if not patient: MM/DD/YYYY

  • Insurance Name: *

  • Mailing Address: *

  • Mailing City, State & ZIP CODE *

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  • Whom may we thank for referring you to FA Dental?

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  • Any details regarding that referral to us:

  • The reason for your appointment is: *

  • What is the approximate date of your last dental visit/cleaning?

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  • Were X-rays taken at that last visit?

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  • Do your gums bleed when you brush or floss?

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  • Are your teeth sensitive to: *

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  • Does food or floss catch between your teeth?

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  • Have you ever had Periodontal (gum) treatments?

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  • Have you ever had Orthodontic (braces) treatment?

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  • Have you ever had a problem with dental treatment?

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  • Is your mouth dry?

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  • Have you ever had a serious injury to your head/mouth?

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  • Medical Information

  • Have you had a serious illness operation or been hospitalized in the past 5 years?

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  • Are you taking or have you recently taken prescription or over the counter medicine(s)?

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  • If you are taking or have recently taken prescription or over-the-counter medicine(s), please list all, including vitamins, natural or herbal preparations and/or dietary supplements.

  • Any Joint Replacement?

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  • Scheduled to take Fosmax or Actonel for Osteoporosis or Paget's disease?

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  • Allergies (Are you allergic to or have you had a reaction to any of the following?

    Local Anesthetics
    Aspirin
    Penicillin or other antibiotics
    Barbiturates, sedatives or sleeping pills
    Sulfa drugs
    Codeine or other narcotics
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    Latex
    Food
  • Other from above not mentioned?

  • Do you use controlled substances (drugs)?

    Yes
    No
  • Do you use tobacco?

    Yes
    No
  • Do you drink alcoholic beverages?

    Yes
    Rarely
    No
  • Heart

  • Check all that may apply: *

    Artificial valve
    Damage to valve
    Heart Surgery in last 6 months
    Heart Attack
    Blood Pressure Low
    Blood Pressure High
    Stroke
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    Sexually transmitted disease
    Kidney problems
    Liver problems
    Mental Health issues
    Neck Pain
    Neck Glands Swollen
    Stomach problems
    Acid Reflux
    Thyroid Problems
    NONE
  • FA Dental encourages you to discuss any and all relevant health issues prior to treatment with Dr. Fariba Alikhani. I certify that I have read & agree I have given health information completely & accurately. I will not hold FA Dental and my dentist responsible to any action they take or don't take because of errors or omissions that I may have made in the completion of this form. I understand that the responsibility for payment of dental services provided for me or my dependent is mine. Any insurance problems (if applicable) will be communicated to me by the dental office. It is my responsibility to partner with the dental office to assure a smooth connection with any 3rd party coverage plans. I am responsible for CoPay payments at time of visits.

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Copyright © 2023
Fariba Alikhani, DMD

1580 Winchester Blvd.
# 105,
Campbell, CA 95008