LUKASIEWICZ & BELLAVANCE

DATE:___________________________________

EMAIL:__________________________________________________________________________________________________

NAME:___________________________________________________ PREFERRED NAME___________________________

BIRTHDATE:__________________ MARRIED SINGLE MINOR MALE FEMALE

ADDRESS:_________________________________________________________ CITY_________________STATE_____

SOCIAL SECURITY #__________________ HOME PH#___________________________CELL#__________________________

PLACE OF EMPLOYMENT:_______________________________WORK#______________________________________________

IF FULL TIME STUDENT, COLLEGE NAME:__________________________________________

DENTAL INSURANCE CO:__________________________SUBSCRIBER#___________________GROUP#_________________

HAS ANY MEMBER OF YOUR FAMILY EVER BEEN TREATED IN OUR OFFICE?___________________________________

WHOM MAY WE THANK FOR REFERRING YOU TO THE OFFICE?________________________________________________

FATHER (OR HUSBAND) MOTHER (OR WIFE)

________________________________________________ _____________________________________________ LAST FIRST MI LAST FIRST MI

___________________________________________________________ _________________________________________________________ STREET CITY STATE ZIP STREET CITY STATE ZIP

___________________________________________________________ _________________________________________________________ BIRTHDATE BIRTHDATE

___________________________________________________________ _________________________________________________________ EMPLOYER EMPLOYER

___________________________________________________________ _________________________________________________________ DENTAL INSURANCE SUBCRIBER # GROUP # DENTAL INSURANCE SUBSCRIBER # GROUP #

Please Check One

Name__________________________________ Patient

Address________________________________ Guardian

Father (or Husband)

Mother (or Wife)

City/State/Zip___________________________

Telephone #____________________________

I hereby authorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I understand that I am

responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic

and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/medical histories are correct

to the best of my knowledge. I grant the right to the dentist to release my dental/medical histories and other information about my dental

treatment to third party payors and/or other health professionals.

____________________________________________ ____________________________

Patient signature (or if under 18, parent/guardian) Date

PATIENT INFORMATION

PERSON TO CONTACT IN CASE OF EMERGENCY

AUTHORIZATION

PERSON RESPONSIBLE FOR ACCOUNT

Patient Name:

LUKASIEWICZ _BELLAVANCE LLC Eaglesoft Medical History

Birth Date:

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body, Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Oves QNo

Qves QNo

Oves QNo

QYes QNo

Are you under a physician's care now?

Ha Ye you eyer been hospitalized or had a major op eration?

Have you ever had a serious head or neck injury?

Are you taking any medications, pi l ls, or drugs?

Do you take, or hav e you taken, Phen-Fen or Redux? Qves QNo

Have you ever taken Fosamax, Boniva, Acton el or any other Oves QNo medications containing bisphosphona!es?

Are you on a special diet? OYes QNo

Do you use tobacco? QYes QNo

Do you use controlled substances? Qves QNo

Women: Are you .. , O Pregnant/Trying to get pregnant? □ Nursing?

Are you allergic to any of the following? □ Penicillin

OLatex

□Aspirin

OMetal

Other? □

Do you have, or have you had, any of the following?

AID 5/H N Positive Oves QNo Cortisone Medicine

Alzheimer's Disease Oves QNo Diabetes

Anaphylaxis Oves QNo Drug Addiction

Anemia Oves QNo Easily Winded

Angina Oves QNo Emphysema

Arthritis/Gout Oves QNo Epilepsy or Seizures

Artif icial HeartValve Oves QNo Excessive Bleeding

Artificial Joint Oves QNo Excessive Thirst

Asthma Oves QNo Fainting Sp ells/Dizziness

Blood Disease Oves QNo Frequent Cough

Blood Transfusion Oves QNo Frequent Diarrhea

Breathing Problems Oves QNo Frequent Headaches

Bruise Easily Oves QNo Genital Herpes

Cancer Oves QNo Glaucoma

Chemotherapy QYes QNo Hay feyer

Chest Pains QYes QNo Heart Atta ck/Failure

Cold Sores/Fever Blisters QYes QNo Heart Murmur

Congenital Heart Disorder QYes QNo Heart Pace.maker

Convulsions QYes QNo Heart Trouble/Disease

Yellow Jaundice Qves QNo

Oves

Oves

Oves

Oves

Oves

Oves

Oves

Oves

Oves

Oves

Oves

Oves

Oves

Oves

QYes

QYes

QYes

QYes

QYes

Have you ever had any serious illness not listed above? QYes QNo

Comments:

If yes

If yes

If yes

If yes

If yes

QNo

QNo

QNo

QNo

QNo

QNo

QNo

QNo

QNo

QNo

QNo

QNo

QNo

QNo

QNo

QNo

QNo

QNo

QNo

If yes

�-------------------------------�

�===============================================================� �-------------------------------�

�-------------------------------�

□ codeine

O Sulfa Drugs

□ Taking oral contraceptives?

□Acrylic

O Local Anesthetics

�-------------------------------�

Hemophilia 0Yes QNo Radiation Treatments Oves QNo

Hepatitis A Oves QNo RecentWeightLoss Oves QNo

Hepatitis B or C QYes QNo Renal Dialysis Oves QNo

Herpes QYes QNo Rheumatic Fever Oves QNo

High Blood Pressure QYes QNo Rheumatism Oves QNo

High Cholesterol 0Yes QNo Scar let Fever Oves QNo

Hives or Rash 0Yes QNo Shingles Oves QNo

Hypoglycemia 0Yes QNo Sickle Cell Disease Oves QNo

Irregular Heartbeat 0Yes QNo Sinus Trouble Oves QNo

Kidney Problems 0Yes QNo Spina Bifida Oves QNo

Leukemia 0Yes QNo stoma ch/Intesti n a I Disease Oves QNo

Liver Disease 0Yes QNo stroke Oves QNo

Low Blood Pressure 0Yes QNo Swelling of Limbs Oves QNo

Lung Disease OYes QNo Thyroid Disease Oves QNo

Mitra I Valve Prolapse QYes QNo Tonsillitis QYes QNo

Osteoporosis QYes QNo Tuberculosis QYes QNo

Pain in Jaw Joints QYes QNo Tumors or Growths QYes QNo

Parathyroid Disease QYes QNo Ulcers QYes QNo

Psychiatric Care QYes QNo Venereal Disease QYes QNo

To the best of my knowledge, the questions on this form have been accurately answered, I understand that providing incorrect information can be dangerous to my (or patient's) health, It is my responsibility to inform the dental office of any changes in medical status,

Signab.Jre of Patient, Parent or Guardian:

X----------------------------------------------- Date:

Lukasiewicz & Bellavance

Dental History

Please help us to learn more about your dental history by answering the following questions. This series of questions is

designed so that we are able to accommodate your specific dental needs.

• What did you like or dislike about your previous Dentist/Dental office?

____________________________________________________________________________________

• What is the approximate date of your last visit to the Dentist? __________________________________

Dentist Name: ___________________________________

Please circle Yes or No to the following:

Do you feel nervous about having dental treatment:? YES NO

Have you had any trouble associated with previous dental treatment?: YES NO

Have you ever had gum treatments?: YES NO

Are you unhappy with your smile?: YES NO

Do you usually use ‘novacaine’ for dental treatment?: YES NO

Missed Appointment Policy

We do our best to keep the cost of your dental treatment as economical as possible. The appointment you schedule for treatment is

reserved for you and your treatment only. When you fail to keep your appointment without providing us with 48 hours notice, another

patient who could have been seen was not. This adds to the overall cost of care, as trained personnel and dental facilities are not being

utilized.

In the event you have three (3) missed appointments, we will be unable to afford to help you as a patient, considering the time we

lose each time you fail to keep an appointment.

Initials____________________

HIPAA

The Health Insurance Portability and Accountability Act

I,__________________________, have received and reviewed a copy of this office’s notice of Privacy

Practices.

__________________________ ____________________________ ______________________

Printed Name Signature Date

EMAIL: NAME: ADDRESS: CITY: STATE: HOME PH: CELL: PLACE OF EMPLOYMENT: WORK: IF FULL TIME STUDENT COLLEGE NAME: DENTAL INSURANCE CO: SUBSCRIBER: GROUP: HAS ANY MEMBER OF YOUR FAMILY EVER BEEN TREATED IN OUR OFFICE: WHOM MAY WE THANK FOR REFERRING YOU TO THE OFFICE: LAST: LAST_2: STREET: STREET_2: BIRTHDATE_2: BIRTHDATE_3: EMPLOYER: EMPLOYER_2: DENTAL INSURANCE: DENTAL INSURANCE_2: Name: Address: CityStateZip: Telephone: Group1: OffDate2_af_date: Date4_af_date: PREFERRED NAME: undefined_5: undefined_3: Offundef: OffPrint: RESET: SAVE: 1prime: 1Date7_af_date: Group9: Off1: Group10: Off2: Group11: Off3: Group12: Off4: Group13: Off5: Group14: Off6: Group15: OffGroup151: Off7: Group16: Off8: Check Box1012: OffCheck Box1112: Off12121: OffCheck Box10: OffCheck Box11: Off12: Off1122: Offa: Offb: Offc: Offd: Offj: OffIf yes: 9: Groupb: Offa1: Offb8: Offd1: Offq: Offa2: Offb9: Offd2: Offw: Offa3: Offb10: Offd3: Offr: Offa4: Offc1: Offd4: Offt: Offa5: Offc2: Offd5: Offy: Offa6: Offc3: Offd6: Offu: Offa7: Offc4: Offd7: Offi: Offa8: Offc5: Offd8: Offo: Offa9: Offc61: Offd9: Offp: Offa10: Offc6: Offd10: Offs: Offa11: Offc7: Offd11: Offf: Offa12: Offc8: Offd12: Offh: Offb1: Offc9: Offd13: Offk: Offb2: Offc10: Offd14: Offl: Offb3: Offc11: Offd15: Offz: Offb4: Offc12: Offd16: Offx: Offb5: Offc14: Offd17: Offv: Offb6: Offc13: Offd18: Offn: Offb7: Offc15: Offd1821: Offm: OffIf yes_2: Groupa: OffComments: What did you like or dislike about your previous DentistDental office: Date5_af_date: Dentist Name: Group8: OffInitials: I: undefined: Date7_af_date: