Medical History 

Do you have or ever had:

Please Indicate if:

NA if not applicable

PAYMENT IS REQUIRED ON THE DAY OF TREATMENT

Please note West Beach Dental does not accept E.D.S or P.D.S Government forms.

 

 I have completed this Patient History Sheet to the best of my knowledge, and understand that failure to make a full disclosure may place ME at undue medical risk. I also give my permission for the practice to use the above contact details to send me Checkup reminders. I agree to assume FULL financial responsibility and to pay ALL DEBT COLLECTION costs incurred resulting from my default on ALL overdue amounts for all treatment rendered.