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.
I authorize Pine Coast Orthodontics 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.