Dental Clinic Appointments

It is important for you to realize that you will be treated by a dental hygiene student and that your appointment may take up to three hours and you may be asked to return for a number of appointments.

Name

Date of Birth

Gender

Female Male

Street Address

Town

State

Zip Code

Home Phone

Cell Phone

Do you have insurance?

Yes No

If you have insurance, who is your provider?

Service Requested

Cleaning

X-rays

Exam

Other services you are requesting

When was your last dental appointment?

Reason for and services provided at last appointment:

Are you being treated by a physician?

Yes No

If so, for what condition?

Do you take blood thinners?

Yes No

If yes was answered to any of the above, Physicians Name and contact number

Have you had surgery in the last 3 years?

Yes No

If you have had surgery in the last 3 years, what was the surgery for?

Do you need to be premedicated before dental appointment?

Yes No

If you are human leave this field blank