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OC Healthy Smiles
Free custom whitening trays for all new patients

Health History Form

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Our 5-star-rated Costa Mesa Dental Office

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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.
Oc Healthy Smiles

2900 Bristol st. A205
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 – Closed
Saturday – 8:00AM – 1:00PM
Sunday – Closed