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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

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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