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North Suburban Center
Oral & Facial Surgery

Aaron D. Figueroa, DDS
Kyle J. Hresko, DDS
Michael J. Nick, DDS
Mark J. Steinberg, DDS, MD
Diplomates, American Board of Oral & Maxillofacial Surgery

1240 Meadow Road • Suite 300 • Northbrook, Illinois 60062
810 S Waukegan Rd • Suite E • Lake Forest, Illinois 60045
7500 Grand Avenue • Suite 101 • Gurnee, Illinois 60031

Phone: 847-272-9516
Fax: 847-272-9551
www.nscoms.com

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Doctor and Referral Information

Referred By

Current Dentist

Medical Doctor

Who Will Be Responsible for Payment of This Account?

Who will be responsible for payment of this account?

Self Spouse Father Mother Other

Name

Birth Date / Age / E-mail

Home / Cell Phone

Address

City / State / Zip

Employer / Bus. Phone

Primary Dental Insurance Company

I.D. #

Ins. Co. Name

Copy of Card

Yes No

Ins. Co. Address

City / State / Zip

Tel. / Plan / Group #

Group Name

Insured Party

Relation

Sex:

M F

Ins. Party Address

City / State / Zip

Birth Date / Tel.

Primary Medical Insurance Company

I.D. #

Ins. Co. Name

Copy of Card

Yes No

Ins. Co. Address

City / State / Zip

Tel. / Plan / Group #

Group Name

Insured Party

Relation

Sex:

M F

Ins. Party Address

City / State / Zip

Birth Date / Tel.

Additional Medical Information

Is there any condition concerning your health that the Doctor should be told about?

Yes No

Do you wish to speak to the doctor privately about anything?

Yes No

Is there a FAMILY HISTORY of:

Cancer

Yes No

Diabetes

Yes No

Heart Disease

Yes No

Anesthetic Problems

Yes No

Emergency Contact

Name

Phone

Is This Visit Related to an Accident?

Is this visit related to an accident? If yes, what type?

Automobile

Work related

Other

Date of Injury

Insurance Co. / Claim Number

Attorney / Adjustor Name & Phone

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

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

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 surgeon, 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:-------------

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. I authorize the taking of all imagining, including x-rays and CBCT scans, as a necessary part of this examination. In addition, I authorize the release of any information acquired in the course of my examination and treatment for medically necessary purposes, including the release of all information required to process my insurance claim.

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.

FEES AND PAYMENTS

We make every effort to deliver the finest care at the most reasonable cost to our patients. We request payment at the time of service and accept Visa, Mastercard, American Express, and Discover, along with check or cash. We will prepare a treatment plan at your initial visit to provide you with the estimated costs of your proposed procedure. We are in network with many dental insurance companies and will submit a claim on your behalf when appropriate. We are out of network with all medical insurance companies but will submit a claim to your medical insurance as a courtesy, if we perform a medical procedure. It is the patient’s responsibility to know their insurance benefits and to provide all information needed to submit a claim, including copies of your insurance ID cards, name and date of birth of primary insured, and the insurance ID and group number. Any balance after insurance is the patient responsibility. If balance is unpaid, you will be sent to collections and will be responsible for all collection costs, attorney fees and court costs.

Signature of patient: (Parent or Guardian if minor)

Click to Sign

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

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North Suburban Center
Oral & Facial Surgery

Demographic Information

Patient Information

Doctor and Referral Information

Who Will Be Responsible for Payment of This Account?

Insurance Information

Insurance Information

Primary Dental Insurance Company

Primary Medical Insurance Company

Health History

Health History

Have You Had or Do You Currently Have...

Medications and Allergies

Are you now taking or have you taken...

Are you allergic to, or had a reaction to...

Conclusion

Additional Medical Information

Is there a FAMILY HISTORY of:

Emergency Contact

Is This Visit Related to an Accident?

This Section Is for Women Only

Verification

Click to Sign

Click to Sign

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Main Header

North Suburban CenterOral & Facial Surgery

Demographic Information

Patient Information

Doctor and Referral Information

Who Will Be Responsible for Payment of This Account?

Insurance Information

Insurance Information

Primary Dental Insurance Company

Primary Medical Insurance Company

Health History

Health History

Have You Had or Do You Currently Have...

Medications and Allergies

Are you now taking or have you taken...

Are you allergic to, or had a reaction to...

Conclusion

Additional Medical Information

Is there a FAMILY HISTORY of:

Emergency Contact

Is This Visit Related to an Accident?

This Section Is for Women Only

Verification

Click to Sign

Click to Sign

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North Suburban Center
Oral & Facial Surgery

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