Health History Form


HEALTH HISTORY FORM

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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714.422.0596


1202 Bristol St #140
Costa Mesa, CA 92626
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Dr. Nguyen and his award-winning Costa Mesa, CA dentists, Costa Mesa, CA cosmetic dentists and Costa Mesa, CA pain-free dentists offer 5-star rated and comfortable dental care for children and adults, including teeth cleanings, dental implants, veneers, teeth whitening, Invisalign and more. We are your all-in-one dental office in Costa Mesa, CA!
Call 714.422.0596 today for your OC Healthy Smiles dental checkup at our conveniently located link textdental office in Costa Mesa, CA. Come experience OC Healthy Smiles and you will see our Costa Mesa dentists and cosmetic dentists offer comfortable dental care with a smile to patients near Costa Mesa, Newport Beach, Newport Coast, Irvine, Fountain Valley, Corona del Mar, Huntington Beach, Tustin, Laguna Beach, Santa Ana, California (CA).
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