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: