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Mark McGee D.D.S., PC


Personal Information

  • Mr./Mrs./Ms./Miss (Last)
  • (First)
  • (MI)
  • What name shall we call you?
  • Date of Birth
  • Home address
  • City
  • State
  • Zip
  • E-mail address
  • Home phone
  • Cell phone
  • Driver Lic#
  • State
  • Employer
  • Occupation
  • Work phone
  • Address
  • City
  • State
  • Zip
  • Spouse Name
  • Children(s) names
  • Parent /guardian name if minor
  • Emergency contact
  • Relation
  • Telephone
  • Who may we thank for referring you?


Insurance Information

  • Name of insured
  • Relationship to patient
  • Birth date
  • Date employed
  • Name of employer
  • Work phone#
  • Name of Ins Co.
  • Group#
  • Id#
  • Insurance Phone#
  • To avoid any misunderstanding concerning your dental insurance, we wish our patients to know that all professional services rendered are
    charged directly to the patient and that patients are personally responsible for payment of fees. We do not render services on the basis that
    the insurance companies will pay our fees unless a pre-determination of benefits has been established. We will assist you in filing all
    insurance forms. Payment is due when services are rendered unless other arrangements have been made. If you must change a scheduled
    appointment, please inform us as soon as possible. If we are not notified before 3:00 PM the working day prior to your appointment, then
    we may regrettably charge your account.

  • I hereby authorize Dr. McGee to take radiographs, study models, photographs or any other diagnostic aids deemed necessary to make a
    thorough diagnosis for my dental needs. I also authorize the doctor to prescribe any and all forms of medication, and to perform any
    therapy that may be indicated and agreed upon.

  • I further authorize the release of any information including the diagnosis and records of any treatments or examinations rendered to my
    insurance company or consulting professionals. The release to the insurance company is solely for the purpose of facilitating the billing and
    reimbursement directly to the dentist for insurance benefits under which I am entitled. I understand the responsibility for payment for
    serviced rendered for myself and my family are due and payable at the time the service is rendered.

  • Signature of patient or responsible party
  • Date


Please check either Yes or No as applicable:
Do you have or have ever had any of the following?
  • Yes No
    HYPOGLYCEMIA
    DIABETES
    HEART ATTACK
    HEART TROUBLE
    HAY FEVER, ASTHMA, ALLERGIES
    CIRCULATORY PROBLEMS
    HEPATITIS
    JAUNDICE
    LUNG PROBLEMS
    TUBERCULOSIS
    EPILEPSY, SEIZURE
    BLOOD TRANSFUSIONS
    FACIAL OR HEAD INJURIES
    RADIATION
    CHEMOTHERAPHY
    MALIGNANCIES
    CANCER
    AIDS
    HIV POSITIVE
    ARTHRITIS
    PROSTHETIC VALVES
    HIGH BLOOD PRESSURE
  • Yes No
    SPINAL FUSION
    ARTIFICIAL JOINTS OR IMPLANTS
    STROKE
    OSTEOPOROSIS
    SINUS PROBLEMS
    HEART MURMUR
    MITRAL VALVE PROLAPSE
    RHEUMATIC FEVER
    ANEMIA
    BLOOD DISORDER
    EXCESSIVE BLEEDING
    FAINTING, BLACKOUTS
    NERVOUS DISORDER
    HEADACHES, MIGRAINES
    KIDNEY PROBLEMS
    GLAUCOMA, EYE PROBLEMS
    ULCERS
    DIGESTIVE PROBLEMS
    HISTORY OF EATING DISORDERS
    ARE YOU PREGNANT NOW?
    LOW BLOOD PRESSURE
    LATEX ALLERGY

  • Date:


  • Date:
  • Do you have allergies to any of the medications listed below? (Please check)
  • AspirinCodeineAnestheticsXylocaineNovocaine
    SedativesPenicillinErythomycinLidocaineSulfa
  • Other Antibiotics:
  • Have you noticed any of the following?
  • Yes No
    Discomfort in face, head, neck, jaw
    Loose teeth
    Food caught between teeth
    Sensitivity to sweets, hot or cold
    Teeth tender when chewing
  • Yes No
    Jaw clicking or popping
    Swelling lumps in mouth
    Bleeding or sore gums
    Recurring sore in or around the mouth
  • Name & Phone # of Physician:
  • Have you been hospitalized in the last year? If yes explain,
  • Please list any drugs currently being taken:
  • Do you consume alcohol or use tobacco?
  • YesNo
  • In what quantities?
  • Reason for this dental visit
  • Date of last dental visit
  • Have you ever been treated by a periodontist, orthodontist or endodontist?
  • YesNo
  • If yes explain:
  • Date of last x-rays
  • Are you happy with the appearance of your teeth?
  • YesNo
  • THE INFORMATION ABOVE IS CORRECT TO THE BEST OF MY KNOWLEDGE.
  • SIGNATURE:
  • DATE:

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