1580 N Northwest Hwy, Suite 300Park Ridge, IL 60068

First Name: MI: Last Name: Title:

Date

Nickname

Mailing Address:

City: State:

Sex: Marital Status:

Age:

Home Phone:

Cell Phone:

First Name: MI: Last Name: Title:

Mailing Address:

City: State: ZIP:

Birth Date: Age:

Home Phone:

Cell Phone:

Patient Information:

Insurance Information (if different from above):

Employer:

School:

Occupation:

Student:

Birth Date:

Employer: Occupation:

Work Phone:

Work Phone:

All personal information is held in the strictest confidence.

Spouse Name:

Have you been a patient of our practice before:

Who is responsible for this account:

Referral Information:

Who referred you to our office:

General Dentist:

Orthodontist:

Physician:

Phone:

Phone:

Phone:

ZIP:

Spouse Name: Occupation:

Pharmacy: Phone:

SS#:

SS#:

File # __________

Medical History:

Yes No

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

Yes NoHeart attack Diabetes

Yes NoHeart surgery

Irregular heart beat Yes No

Yes NoHigh blood pressure

Yes NoCOPD / emphysema

Yes NoKidnery failure / dialysis

Yes NoHepatitis / liver disease

Yes NoStroke / CVA

Yes No

Seizures / epilepsy

Yes NoBleeding disorders

Yes No

Asthma Yes No

Yes NoThyroid disease

Autoimmune disorders Yes No

Immune system deficiency Yes No

Drug / alcohol addiction Yes No

Anxiety / psychiatric care Yes No

Painful / clicking jaw joints Yes No

Cancer / malignancy Yes No

Chemotherapy Yes No

Radiation therapy Yes No

Site:

Yes No Have you ever taken drugs to treat osteoporosis (Boniva, Fosamax, Actonel, Zometa, Aredia)?

Yes No Blood thinners (Coumadin, Plavix, Aspirin, Eliquis, Pradaxa, Xarelto)?

Yes No Smoke or vape?

Yes No

Artificial heart valve?Yes No

Illnesses or conditions not listed above:

Pregnant or breastfeeding?Yes No

Patient Signature: Date:

Doctor Signature: Date:

Please list all previous surgeries:

Please list any allergies (e.g. medicines, latex):

Please list all current medications : (attach a sheet for long lists)

Yes NoQuit? Year:

Blood clots / DVT / PE

Artificial joints (hip / knee / shoulder) ?

File # __________

Primary Dental Insurance

Insurance Carrier:

Name of Insured:

Group Name:

Group #:

ID #:

Policy Plan:

Secondary Dental Insurance

Insurance Carrier:

Name of Insured:

Group Name:

Group #:

ID #:

Primary Medical Insurance

Insurance Carrier:

Name of Insured:

Group Name:

Group #:

ID #:

Secondary Medical Insurance

Insurance Carrier:

Name of Insured:

Group Name:

Group #:

ID #:

Policy Plan:

Policy Plan: Policy Plan:

File # __________

Name: Birth Date:

MEDICAL INFORMATION RELEASE FORM(HIPAA FORM)

Authorize:

File # __________

Messages:

Signature of patient / legal representative: Date:

Home

If unable to reach me:

Please call:

I authorize the release of information including the history, examination, diagnosis, and treatment rendered to me, andclaims and billing information. This information may be released to:

Cell

This Release of Information will remain in effect until terminated by me in writing.

Information is not to be released to anyone.

Leave a detailed message

Leave a message asking me to return your call

Spouse:

Parents:

Children:

Other:

Other:

1580 N Northwest Hwy, Suite 300Park Ridge, IL 60068

Thank you for choosing James G. Loeser DDS, MD for the highest quality oral, maxillofacial and implant surgical care. Toprevent misunderstanding concerning your responsibility regarding payment for services rendered, the following isunderstood:

Financial Policy: Both a social security number and a credit card on file is required. If you have benefits forthe services that were provided, a claim will be submitted to your insurance company, Any remaining balance (resultingfrom deductible, co-insurance, etc.) is then charged to your credit card on file. After 60 days, unpaid balances willbe turned over to a collection agency; the patient and/or patient guarantor is responsible for all collection costs.

PPO Dental/HMO: If you plan to use your insurance benefits, we will require a copy of your insurance card, a driver'slicense and your social security number. All co-payments are due prior to seeing the doctor. Failure to provide allnecessary information may require you to pay in full on the date of the visit or subsequent to treatment. You areresponsible for any services that are not a covered benefit under your insurance plan and/or are not consideredmedically necessary by the insurance company. Patient portions are due the day of surgery. There is a $25 processingfee for filing with your dental insurance. Please note: If services are not a covered benefit in your plan, the fees will notbe reduced (per Illinois97th general assembly law SB3242).

PPO Medical: We are out of network with all medical insurance plans. Payment will be due in full for services rendered.If there is a payment issued to us from your insurance company, you will be reimbursed the amount issued.

Medicare: Dr. Loeser is NOT a Medicare provider. Dental services are NOT a covered benefit of Medicare. Fees aredue in full the day of services.

Pathology Fees: If a specimen is taken, there will be a separate fee from the pathologist/independent pathologylaboratory.

Self-Pay Patients: For patients without insurance, payment is due at the time of service.

Payments: Payments over 30 days are subject to a 3% fee.

Returned Checks: A charge of $50 will be made for all returned checks.

Payment Plans: Payment plans can be arranged PRIOR to services rendered. A credit card must be on file and will berun on specific dates. If your credit card information changes it is YOUR responsibility to contact us with the newinformation. If your card is declined, the balance will be due in full and the payment plan will be voided.

Appointment Cancellation Fee: If you are unable to keep your appointment, please call at least 24 hours in advanceand speak with someone in our office or leave a message. Insufficient notice may subject you to a $20 fee.

My signature below indicates my understanding and full responsibly for the balance on my account for any professionalservices.

File # __________

1580 N Northwest Hwy, Suite 300Park Ridge, IL 60068

Signature of patient / legal representative: Date:

COVID-19 PANDEMIC - PATIENT DISCLOSURES

This patient disclosure form seeks information from you that we must consider before making treatment decisions in thecircumstance of the COVID-19 virus.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD,cancertreatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greaterrisk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understandthat we may ask you to consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether youhave experienced any signs or symptoms associated with the COVID-19 virus.

Yes No

Do you have a fever or above normal temperature?

Have you experienced shortness of breath or had trouble breathing?

Do you have a dry cough?

Do you have a runny nose?

Have you recently lost or had a reduction in your sense of smell?

Do you have a sore throat?

Have you been in contact with someone who has tested positive forCOVID-19?

Have you tested positive for COVID-19?

Have you been tested for COVID-19 and are awaiting results?

Have you traveled outside the United States by air or cruise ship inthe past 14 days?

Have you traveled within the United States by air, bus or train withinthe past 14 days?

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune systemand have disclosed to my provider any conditions in my health history which may result in a compromised immunesystem.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.

Signature of patient / legal representative: Date:

Witness:

File # __________

1580 N Northwest Hwy, Suite 300Park Ridge, IL 60068

COVID-19 PANDEMIC EMERGENCY DENTAL TREATMENT

NOTICE AND ACKNOWLEDGEMENT OF RISK FORM

Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community.This document provides information we ask you to acknowledge and understand regarding the COVID-19 virus.

The COVID-19 virus is a serious and highly contagious disease. The World Health Organization has classified it asa pandemic. You could contract COVID-19 from a variety of sources. Our practice wants to ensure you are aware of theadditional risks of contracting COVID-19 associated with dental care.

The COVID-19 virus has a long incubation period. You or your healthcare providers may have the virus and not showsymptoms and yet still be highly contagious. Determining who is infected by COVID-19 is challenging and complicateddue to limited availability for virus testing.

Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristicsof dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.

Dental procedures create water spray which is one way the disease is spread. The ultra-fine nature of the water spraycan linger in the air for a long time, allowing for transmission of the COVID-19 virus to those nearby.

You cannot wear a protective mask over your mouth to prevent infection during treatment as your health care providersneed access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dentaltreatment.

Pursuant to statements from the Center for Disease Control (CDC) and the American Dental Association (ADA), non-essential or elective treatment, based on the assessment of our staff, will be rescheduled. According to the ADA, dentalemergencies are "potentially life threatening and require immediate treatment to stop ongoing tissue bleeding [or to]alleviate severe pain or infection." The ADA also recommends that urgent dental care which "focuses on themanagement of conditions that require immediate attention to relieve severe pain and/or risk of infection and toalleviate the burden on hospital emergency departments" be provided in as minimally invasive a manner as possible.

I confirm that I have read the Notice above and understand and accept that there is an increased risk of contracting theCOVID-19 virus in the dental office or with dental treatment. I further confirm I am seeking treatment for a conditionthat meets the emergent or urgent criteria noted above. I understand and accept the additional risk ofcontracting COVID-19 from contact at this office. I also acknowledge that I could contract the COVID-19 virus from outsidethis office and unrelated to my visit here.

I have read and understand the information stated above.

File # __________

1580 N Northwest Hwy, Suite 300Park Ridge, IL 60068

Signature of patient / legal representative: Date:

Witness: