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Dental Hygiene Online Registration Form
THE DENTAL CLINIC OPERATES DURING THE ACADEMIC YEAR FROM SEPTEMBER TO APRIL, HOWEVER YOU CAN SUBMIT THIS REGISTRATION FORM ANYTIME.
Please note that we are experiencing a high volume of client requests. The current wait period is over 1 year.
Client Name:
*
First
Last
Client Date of Birth:
*
MM
/
DD
/
YYYY
Phone Number:
*
###
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###
-
####
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
N/A
If you have diabetes, is it controlled?
*
Yes
No
N/A
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
Do you have reliable transportation for your appointments?
*
Yes
No
Students have specific days/times in the clinic. We have clinic times available from Tuesday to Friday, including morning, afternoon, and evening appointments. When are you available?
*
