Interested in being a patient?
Dental Clinic Address:
University of Hawaii at Manoa Dental Hygiene Clinic (UHDH)
2445 Campus Road, Hemenway Hall, Room 200
Honolulu, HI 96822

Please fill out form to the best of your knowledge and I will respond back to you as soon as possible!
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Email *
First and Last name *
Best contact number (please add area code) *
How do you prefer to be contacted? *
What day(s) of the week works best for you? *Clinic is closed on the weekends* *
Required
What is your usual mode of transportation? *
Were you ever a patient of the UH Manoa Dental Hygiene Clinic before? *
About how long ago was your last dental cleaning? *
How long ago was your last dental xrays taken? *
Who is the Dentist or dental office that did your last cleaning and/or xrays? (Please type the Dentist first and last name or office name. If you don't know or don't remember, please type that in) *I will need to contact their office to request a copy of your xrays to my school* *
What is your DOB mm/dd/yy (Some dental offices may require that I provide your DOB in order for them to release any dental records) *
Are you in any dental pain? *
Are you currently in orthodontic treatment? *
Are you taking any medications: Over-the-counter, Prescribed, Vitamin(s), Supplement(s)? (If YES, please specify. If NO, please put "no") *
Any allergies? (If YES, please specify to what and your reaction. If NO, please put "no") *
Any heart issues: heart defect, heart murmur, past or recent stroke/heart attack, high or low blood pressure? (If YES, please specify to what and your reaction. If NO, please put "no") *
Any past or recent major surgeries or been hospitalized? (If YES, please put what type of surgery and/or reason for hospital visit. 
If NO, please put no)
 *
How did you hear about this opportunity? *
The appointment will be held at UHDH Clinic (address at top of page). This is a learning facility for dental hygiene student clinicians. Therefore, UHDH faculty (Licensed Dentists and Dental Hygienist) will be in the clinic for the duration of the appointment time. *
No dental insurance needed! UHDH charges $25 for the dental cleaning, thorough comprehensive oral examination, xrays (as needed), and fluoride (optional).  *Exact CASH ONLY* *
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