EmailMe Form - Dental Hygiene Online Registration Form

Client Name: *

First Last

Client Date of Birth: *

MM / DD / YYYY

Phone Number: *

### - ### - ####

Can we leave a message? *

Yes

No

Email Address: *

Please answer the following questions:

Have you been a client at our Dental Clinic in the past? If so, when?

How long ago did you last have your teeth cleaned? *

Do your gums bleed when you brush your teeth?

Yes

No

Are you taking any medication? *

Yes

No

If yes, what for?

Do you smoke or vape? *

Yes

No

If you have high blood pressure, is it controlled? *

Yes

No

If you have diabetes, is it controlled? *

Yes

No

Have you had any surgery in the last six weeks? *

Yes

No

Have you ever had a heart attack or stroke? *

Yes

No

If yes, when?

Are you required to take antibiotic premedication prior to dental treatment? *

Yes

No

Are you required to take antibiotic premedication prior to dental treatment? *

Yes

No

Do you have reliable transportation for your appointments? *

Yes

No

Students have specific days/times in the clinic. Please select which days and times you are available. Please note that you will be contacted when an appointment time becomes available for you.