Temple College Dental Hygiene Patient Interest Form
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Patient's First Name *
If Patient is a minor, please provide Guardian's name
Phone number  *
Patient's Age Category *
When was Patient's last cleaning? *
When were Patient's last xrays taken? *
If you know what kinds of xrays were taken, please specify below: (ex: xray for a filling/crown, full mouth xrays, panoramic, xrays for braces, etc)
Does the Patient have any of the following conditions? *
Required
Please list any Patient's allergies *
Please list any medications and doses Patient is taking: *
Does the Patient currently have any of the following: *
Required
Is the Patient a smoker? *
Do the Patient's gums bleed when brushing? *
Patient's language (please choose more than one if either one works)
Since Temple College is a teaching institution, each Patient will need to come in for multiple appointments. For a Patient with light build up, we usually need 1 or 2 appointments. For heavy build up, an average of 3 - 5 appointments. Also, every new adult Patient will need to come in for a free quick screening first. Children (age 6-17yo) don't need a screening and usually need only 1 or 2 appointments. School notes provided. Each appointment can take up to 3 hours since we need to wait for our instructors to double check each step.
The one-time fee is $15 (only cash or check)
Clinic address: Temple College Dental Hygiene Clinic
2511 S 1st St, Temple, TX 76504
 *
What days work best for scheduling? Below are the hours for the spring semester of 2023. Fall semester hours might change but still won't include Fridays, late evenings or weekends. *
Required
How did you hear about the Clinic? *
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