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8100 Penn Avenue South, #172 Bloomington MN, 55431 952. 884. 8337 www.LifesmilesFamilyDentistry.com
Welcome! My staff and I are delighted that you have chosen our office to care for your dental needs. I am proud to provide gentle, family oriented dental care to the adults and children of this community. We utilize state of the art equipment and sterilization techniques. In addition to general dentistry, we offer a variety of cosmetic dentistry services such as veneers, all porcelain crowns, Invisalign orthodontics, tooth whitening, and bonding. Our caring staff believes in providing a comfortable atmosphere during treatment. Please let us know of anything we can do to make your visit as pleasant as possible. Enclosed are patient information forms for you to complete at your convenience. Please bring in the completed forms to your scheduled appointment, along with a government issued ID. If you have insurance, bring in your ID card so that we can make a photocopy of it. Our front office staff is always happy to help you with your insurance needs. Our office is located on Penn Avenue at 82nd Street in the Southtown Office Park building. Free parking is available on the south side of our building. If we can be of further assistance, please feel free to contact us at (952) 884-8337 or visit our website, www.LifesmilesFamilyDentistry.com. Again, we are very happy to have you as a new patient and look forward to meeting you at your scheduled appointment! Sincerely,
Dr. John A. Gawlik, Jr. & Staff
Patient’s First Name
Patient Information
Patient Employer Information
(as it appears on insurance card or ID)Middle Name Last Name
Date of Birth (Age) sutatS latiraMxeS
Patient’s Address ZipStateCity
Referred by Primary Care Physician Primary Care Physician Phone
Social Security Number
Home Phone Mobile Phone Email Address
Employer Occupation Employer Phone
Emergency Contact InformationEmergency Contact Name Emergency Contact Phone Relation to Patient
Insured’s Name (as it appears on insurance card or ID)
Billing and Insurance
Relation to Patient
Insurance Company Insurance Company AddressPrimary Dental Insurance
ID Number
Insured’s Phone Number
Insured’s Address ZipStateCity
Group Number Insured’s Employer
Secondary Dental Insurance
Billing Name (if other than patient)
Responsible PartyRelation to PatientPhone
Address ZipStateCity
Employer Address ZipStateCity
Authorized Signature of Covered Person / Employee
Date
Insured’s Social Security Number Insured’s Birthdate
Insured’s Name (as it appears on insurance card or ID) Relation to Patient
Insurance Company Insurance Company Address
ID Number
Insured’s Phone Number
Group Number Insured’s Employer Insured’s Social Security Number
:tnemtnioppA fo etaD
Signature of Responsible Party Date
I understand that I am financially responsible for all charges. In the event of a default on payment, responsible party will pay collection costs and reasonable attorney fees totaling 40% of this amount and any other future outstanding amounts.
I, the undersigned hereby authorize the release of any information relating to all claims for benefits submitted on behalf of myself and/or my dependents. I further expressly agree and acknowledge that my signature below authorizes my dentist to submit claims for benefits, for services rendered, or for services to be rendered, without obtaining my signature on each and every claim to be submitted for myself and/or my dependents, and that I will be bound by this signaure as though the undersigned had personally signed the particular claim.I, hereby authorize my dental insurance company to pay and hereby assign directly to Lifesmiles Family Dentistry all dental benefits, if any, otherwise payable to me for services described on insurance forms. I understand that I am financially responsible for all charges incurred, less any dental insurance benefits when received by and paid to John A. Gawlik, Jr. DDS. My express authorization is hereby given to release all information necessary to the payment of said benefits.
Dependent Name and DOB Dependent Name and DOB Dependent Name and DOB M F M F M F
Reason for Visit
Excellent Good Fair Poor
Current Medications
Name Dosage
Name Dosage
Name Dosage
Name Dosage
Allergies
Aspirin Penicillin Codeine Acrylic Metal LatexSulfa Drugs Local Anesthetics
Name Reaction
Name Reaction
Past Medical History
Hospitalizations & Surgeries
Reason Date
Reason Date
Women : Are you
Lifestyle Factors
Please Explain:Yes No
Yes No
AIDS/HIV Positive
Artificial Heart Valve
Anaphylaxis
Cortisone Medicine
Anemia
Angina
Arthritis
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Alzheimer’s Diseaser
Hemophilia
Name Gender Age
Pregnant / trying to get pregnant?
Nursing?
Are you under a physician’s care now?
Asthma
Artificial Joint Excessive Thirst
Fainting Spells/Dizziness
Hypoglycemia
Irregular Heartbeatr
Shingles
Sickle Cell Disease
Sinus Trouble
Have you ever been hospitalized or had a major operation?Please Explain:Yes No
Please Explain:Yes No
Have you ever had a serious head or neck injury?
Blood Transfusion
Blood DiseaseFrequent Diarrhea
Frequent Cough
Date of Appointment
Taking Oral Contraceptives?
If Yes: Yes No
Do you take, or have you taken Phen-Fen or Redux?
Please Explain:Yes No
Have you ever taken Fosamax, Boniva, Actonel, or any other medicationscontaining bisphosphonates?
Please Explain:Yes No
Are you on a special diet?
Do you use tobacco?
Yes No
Do you use controlled substances?
Chest Pains
Breathing Problems
Bruise Easily
Cancer
Chemotherapy
Congenital Heart Disorder
Cold Sores/FeverBlisters
Convulsions
Diabetes
Heart Attack/Failure
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Pacemaker
Heart Murmur
Heart Trouble/Disease
Leukemia
Kidney Problems
Osteoporosis
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Parathyroid Disease
Pain in Jaw Joints
Psychiatric Care
Stomach/Intestinal Disease
Spina Bifida
Tuberculosis
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Ulcers
Tumors or Growths
Venereal Disease
Patient Acknowledgement of Receipt of Notice of Privacy Practices and Consent For Use and Disclosure of Health Information
Patient Name:____________________________________________ Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information (PHI) to carry out treatment, payment activities and healthcare operations. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your PHI. I, ______________________, acknowledge receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. My signature will also serve as a PHI document release should I request treatment or radiographs be sent to other attending doctor/facilities in the future. Signature:____________________________________Date:________________________ If this Consent is signed by a parent, guardian or personal representative on behalf of the patient, complete the following: Name of Legal Representative/Guardian: ______________________________ Relationship of Legal Representative/Guardian: ______________________________ Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but did not because: It was emergency treatment _____ I could not communicate with the patient _____ The patient refused to sign _____ The patient was unable to sign _____ Other (please describe) _____ _________________________ Signature of Privacy Officer