North Shore Oral Surgery Group

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NORTH SHORE ORAL SURGERY GROUP

ANDREW P. ABELA, DDS, MSC, ABOMS, FRCD
LAWRENCE J. MONALDO, DDS, MBA, ABOMS
FLORA E. OCAMPO, DDS, ABOMS

100 HIGHLAND AVENUE, SUITE 202
SALEM, MA 01970
PHONE: (978) 745-8774

Who will be responsible for your account?

Self Spouse Father Mother Other

Who will be responsible for your account

Name

Birth Date / Age / Soc. Sec. #

Responsible Party Phone

Email / Driver's License

Address

City / State / Zip

Employer / Phone

Spouse or other guarantor information (if different from above)

Name

Relation to Patient / Phone

Birth Date / Soc. Sec. #

Address

City / State / Zip

Employer / Business Name

Are you a student?

Full Time Part Time Not

School Information

School Name

School Address

City / State / Zip

Primary Dental Insurance Information

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Sex

Male Female

Phone / SSN

Insured Party Address

City / State / Zip

Primary Medical Insurance Information

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Sex

Male Female

Phone / SSN

Insured Party Address

City / State / Zip

Do you have secondary dental or medical insurance?

Yes No

Secondary Dental Insurance Information

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Sex

Male Female

Phone / SSN

Insured Party Address

City / State / Zip

Secondary Medical Insurance Information

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Sex

Male Female

Phone / SSN

Insured Party Address

City / State / Zip

This section is for women only

Is there a possibility of pregnancy?

Yes No

Expected delivery date

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding other methods of birth control.

Are you taking any kind of medication, drug, pills?

Yes No

Please list any medications you are currently taking

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #6

Medication #7

Medication #8

Medication #9

Medication #10

Medication #11

Medication #12

Medication #13

Medication #14

Medication #15

Medication #16

Medication #17

Medication #18

Medication #19

Medication #20

Medication #21

Medication #22

Medication #23

Medication #24

Medication #25

Please list any other medications or antibiotics you are allergic to

Medication / Antibiotic Allergy #1

Medication / Antibiotic Allergy #2

Medication / Antibiotic Allergy #3

Medication / Antibiotic Allergy #4

Medication / Antibiotic Allergy #5

Medication / Antibiotic Allergy #6

Medication / Antibiotic Allergy #7

Medication / Antibiotic Allergy #8

Medication / Antibiotic Allergy #9

Medication / Antibiotic Allergy #10

Is there a FAMILY history of

Cancer

Yes No

Diabetes

Yes No

Heart Disease

Yes No

Anesthesia Problems

Yes No

In case of emergency

Contact:

Phone / Relation

Verification

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

FEES & PAYMENTS

We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

Signature of patient: (Parent or Guardian if Minor)

Click to Sign

Date:-------------

AUTHORIZATION

I authorize my surgeon and his / her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x–rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I permit messages to be left on my phone and / or mobile phone concerning my appointment

I permit the office to communicate with me via text message on my cell phone.

Yes No

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

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North Shore Oral Surgery Group

Main Header

Demographic Information

Patient information

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

Insurance Information

General Insurance Information

School Information

Primary Dental Insurance Information

Primary Medical Insurance Information

Secondary Dental Insurance Information

Secondary Medical Insurance Information

Health History

Health History

Health History Part 2

Have you ever had or do you currently have...

Have you ever had or do you currently have...

This section is for women only

Medications / Allergies

Medications (Are you now taking...)

Are you allergic to or had a reaction to:

Please list any medications you are currently taking

Please list any other medications or antibiotics you are allergic to

Conclusion

Is there a FAMILY history of

In case of emergency

Verification

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Click to Sign

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North Shore Oral Surgery Group

Main Header

Demographic Information

Patient information

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

Insurance Information

General Insurance Information

School Information

Primary Dental Insurance Information

Primary Medical Insurance Information

Secondary Dental Insurance Information

Secondary Medical Insurance Information

Health History

Health History

Health History Part 2

Have you ever had or do you currently have...

Have you ever had or do you currently have...

This section is for women only

Medications / Allergies

Medications (Are you now taking...)

Are you allergic to or had a reaction to:

Please list any medications you are currently taking

Please list any other medications or antibiotics you are allergic to

Conclusion

Is there a FAMILY history of

In case of emergency

Verification

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Click to Sign

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