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Loeser DDS - New Patient Form

Patient Information
All personal information is held in the strictest confidence.
Date
MM slash DD slash YYYY
Name*
First MI Last Title
Nickname / User Name*
Sex*
Marital Status*
Spouse Name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Home Phone
Work Phone
Cell Phone
Date of Birth*
MM slash DD slash YYYY
Age*
Social Security Number*
Employer
Occupation
Student?
School
Have you been a patient of our practice before?*
Is your Insurance Information different from above?
Insurance Information
(if different from above)
Who is responsible for this account?*
Name
First MI Last Title
Home Phone
Work Phone
Cell Phone
Date of Birth
MM slash DD slash YYYY
Age
Social Security Number
Employer
Occupation
Spouse Name
Occupation
Referral Information:
Who referred you to our office?
Referral - Please Specify
General Dentist
Phone
Orthodontist
Phone
Physician
Phone
Pharmacy
Phone
Medical History
Do you have or have you had any of the following?
Heart Attack*
- Yes
- No
Diabetes*
- Yes
- No
Heart Surgery*
- Yes
- No
Thyroid Disease*
- Yes
- No
Irregular Heart Beat*
- Yes
- No
Autoimmune Disorders*
- Yes
- No
High Blood Pressure*
- Yes
- No
Immune System Deficiency*
- Yes
- No
COPD / Emphysema*
- Yes
- No
Drug / Alcohol Addiction*
- Yes
- No
Kidnery Failure / Dialysis*
- Yes
- No
Anxiety / Psychiatric Care*
- Yes
- No
Hepatitis / Liver Disease*
- Yes
- No
Painful / Clicking Jaw Joints*
- Yes
- No
Stroke / CVA*
- Yes
- No
Cancer / Malignancy*
- Yes
- No
Site
Blood Clots / DVT / PE*
- Yes
- No
Chemotherapy*
- Yes
- No
Respiratory Illness / COVID*
- Yes
- No
Radiation Therapy*
- Yes
- No
Seizures / Epilepsy*
- Yes
- No
Asthma*
- 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
Quit?
- Yes
- No
Year
Artificial joints (hip / knee / shoulder)?*
- Yes
- No
Artificial heart valve?*
- Yes
- No
Pregnant or breastfeeding?*
- Yes
- No
Illnesses or conditions not listed above: (separate conditions with comma)
Please list all current medications: (separate medications with comma)
Please list all previous surgeries: (separate surgeries with comma)
Please list any allergies (e.g. medicines, latex): (separate allergies with comma)
Signature*
Date*
MM slash DD slash YYYY
Insurance
Primary & Secondary Insurance
Primary Dental Insurance
Insurance Carrier:
Name of Insured:
Group Name:
Group #:
ID #:
Policy Plan:
Primary Medical Insurance
Insurance Carrier:
Name of Insured:
Group Name:
Group #:
ID #:
Policy Plan:
Secondary Dental Insurance
Insurance Carrier:
Name of Insured:
Group Name:
Group #:
ID #:
Policy Plan:
Secondary Medical Insurance
Insurance Carrier:
Name of Insured:
Group Name:
Group #:
ID #:
Policy Plan:
Medical Information Release Form
(HIPAA FORM)
Name
First Last
Date of Birth
MM slash DD slash YYYY
Authorization
I authorize the release of information including the history, examination, diagnosis, and treatment rendered to me, and claims and billing information. This information may be released to:
- Spouse
- Parents
- Children
- Other
- Information is not to be released to anyone
Spouse
Parents
Children
Other
This Release of Information will remain in effect until terminated by me in writing.
Messages:
Please Call
- Cell
- Home
If unable to reach me
- Leave a detailed message
- Leave a message asking me to return your call
Signature of patient / legal representative:*
Date
MM slash DD slash YYYY
Patient Responsibility
Thank you for choosing James G. Loeser DDS, MD for the highest quality oral, maxillofacial and implant surgical care. To prevent misunderstanding concerning your responsibility regarding payment for services rendered, the following is understood:

Financial Policy: Both a social security number and a credit card on file is required. If you have benefits for the services that were provided, a claim will be submitted to your insurance company, Any remaining balance (resulting from deductible, co-insurance, etc.) is then charged to your credit card on file. After 60 days, unpaid balances will be 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's license and your social security number. All co-payments are due prior to seeing the doctor. Failure to provide all necessary information may require you to pay in full on the date of the visit or subsequent to treatment. You are responsible for any services that are not a covered benefit under your insurance plan and/or are not considered medically necessary by the insurance company. Patient portions are due the day of surgery. There is a $25 processing fee for filing with your dental insurance. Please note: If services are not a covered benefit in your plan, the fees will not be 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 are due in full the day of services.

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

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 be run on specific dates. If your credit card information changes it is YOUR responsibility to contact us with the new information. 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 advance and 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 professional services
Signature of patient / legal representative:*
Date*
MM slash DD slash YYYY

Δ

OFFICE INFORMATION

Office Address:
James G. Loeser, D.D.S., M.D.
109 N. Haven Road
Elmhurst, IL 60126
PHONE:
630-465-5000
Fax:
847-390-0479

OFFICE HOURS

Monday	9:00 am – 5:00 pm
Tuesday	8:00 am – 3:00 pm
Thursday	9:00 am – 4:00 pm
Friday	9:00 am – 2:00 pm

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Demo

Loeser DDS - New Patient Form

Patient Information

Insurance Information

Referral Information:

Medical History

Insurance

Primary Dental Insurance

Primary Medical Insurance

Secondary Dental Insurance

Secondary Medical Insurance

Medical Information Release Form

Authorization

Messages:

Patient Responsibility