Patient's Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Pronoun:
Address:
City:
State:
Zip:
Cell Phone:
2nd/Other Phone:
Email:
Emergency Contact's Name
Relationship to Patient:
Phone #:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Place of employment or School and Grade

Responsible Party(s)

First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Social Security #:
Address:
City:
State:
Zip:
Cell Phone:
2nd Phone:
Email:
Employer:
Occupation:
Length of Employment:
Additional Contact's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Social Security #:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Employer:
Occupation:
Length of Employment:

Dental Insurance Information

Insurance Company:
Policy Holder's Name:
Relationship to Patient:
Insurance Co. Address:
City:
State:
Zip:
Subscriber ID #:
Group No.:
Policy Holder's DOB:
SSN:
Do you have dual dental coverage?
(If yes, complete information below)
Secondary Insurance Company:
Policy Holder's Name:
Relationship to Patient:
Insurance Co. Address:
City:
State:
Zip:
Subscriber ID #:
Group #:
Policy Holder's DOB:
SSN:

Dental and Health History

All past medical and dental history may be important for optimal care. Please take time to be as accurate and thorough as possible in answering the following questions. THANK YOU.

Patient's Physician(s):
Date of Last Physical Exam:
Patient's General Dentist(s):
Date of Last Dental Cleaning:
Reason for seeking orthodontic advice:

What is your/your child's chief concern?
Describe any injuries to your face, mouth or teeth:
List all medications (including non-prescriptions):
List all allergies:

Do you have a latex allergy?
Please mark all that apply
Dental
Medical
Cancer:
Any other serious illness/ailments not listed
Please expand on the above information or add anything you feel is important:

Notice of Privacy Policy

I have reviewed a copy of the Pine Coast Orthodontics Notice of Privacy Practices. Click here to review

Release

I authorize Dr. T. Kevin Sullivan and the orthodontic staff to perform diagnostic procedures and treatment as may be necessary for proper orthodontic care.

I authorize release of any information concerning my (or my child's) health care for advice and treatment provided for evaluation and administering claims for insurance benefits.

I authorize release of any information concerning my (or my child's) health care for advice treatment to interdisciplinary team members.

I authorize the taking of photographs and other diagnostic records before, during and after treatment.

The above information is accurate and complete to the best of my knowledge.