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OC Healthy Smiles

Health History Form

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Our 5-star-rated Costa Mesa Dental Office

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HEALTH HISTORY FORM
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Patient Information

Insurance Information

Dental History

I certify that I have answered the above questions to the best of my ability. If there is any change to my medical status, I will inform the dentist. I consent to treatment as necessary or desirable to the care of the patient first named above, including, but no restricted to whatever medicine, performance of operations and conduct of laboratory, x-rays or other studies that may be used by the attending dentist, or qualified designate. I also acknowledge full responsibility for my payment and agree to pay in full, at the time of service, unless other arrangements are made with the Financial Department.
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Oc Healthy Smiles

1202 Bristol St #140
Costa Mesa, CA 92626

(714) 422-0596

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Hours of Operation

Monday – 7:00AM – 7:00PM
Tuesday – 7:00AM – 7:00PM
Wednesday – 7:00AM – 7:00PM
Thursday – 10:00AM – 7:00PM
Friday – 8:00AM – 1:00PM
Saturday – 8:00AM – 2:00PM
Sunday – Closed