Dental Hygiene Patient Form
Hello! 

My name is Emma and I am a dental hygiene student at Oregon Tech located in Salem, Oregon. 

Oregon Tech Dental Hygiene Clinic at Chemeketa Community College
4000 Lancaster Drive NE Salem, Oregon 97305
Building 8 - Room 101

I am looking for patients to help me continue to learn while also providing you with a high quality, low cost dental experience now and throughout my time at school. If you are interested in becoming a patient or want to get more information, please fill out this form. 

Appointments: 
  • At your first appointment we will evaluate your teeth and mouth and take dental x-rays if needed. Based on these findings we will determine the type of cleaning you need.
  • Appointments range from 1-3 hours and comprehensive treatment will require more than one appointment. This is to ensure a thorough exam for every patient.
We do not accept insurance at our clinic, however all of our services are affordable. 
X-rays: $27-46
Cleanings: $34+
Fluoride Treatments: $8
Sealants: $11 per tooth

Appointment days vary depending on the term. Appointments are either AM (8:30-11:00) or PM (1:30-4:00).

If you are at all interested or want to get some more information, please fill out this form!

THANK YOU!!!
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First and Last name *
Preferred language *
Birthday *
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YYYY
Which do you prefer? *
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Phone Number *
Email *
Do you have a "home" dental office that you have regular appointments? *
If so:
Dentist Name
Office Name
Phone Number
When was your last dental appointment? (Month/year if known) *
What was done at your last dental appointment?
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When were your last dental x-rays? (Month/year if known) *
Do you have a history of any of these? (select all that apply) *
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What day(s) of the week works best for you?

(Summer term days include Tuesdays (AM and PM) and Thursdays (AM and PM)).
 *
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What time of day works best for you? (select all that apply) *
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Do you have any dental concerns?
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Do you have any questions/comments?
If I can't fit you into my schedule now, would it be okay if I reach out in the future? *
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