Client Medical History Questionnaire

Welcome to Ballina Coast Dental. In order to provide you with complete quality care we need to know about your state of
health and medical history. All information provided will be treated in strictest confidence, but if you are more comfortable
discussing personal matters with the dentist, then please do. Thank you.

DENTAL INFORMATION – please tick those that apply

Please notify us at least 24 hours in advance if you need to cancel your appointment. Failure to do so may incur a fee.

Sign Here