Dental Hygiene Appointment Request

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Dental Hygiene Appointment Request

This is a student dental clinic. Appointments may require 2-4 visits, each lasting up to 3 hours. Please be patient, as your participation is greatly appreciated in this learning process!

📍 Address: 1425 NE Irving St, Portland, OR 97232

1. Is this appointment for a child (pediatric patient)?

Yes

Clear selection

If yes, Parent/Guardian's Name:

Full Name (Patient or Child's Name):

Date of Birth *

YYYY

Email *

Phone number *

2. Appointment Preferences

Preferred Appointment Day:

(Mon, Tuesday, Thurs, Fri available only!)

1:00PM-6:30PM

YYYY

Need Accommodation?

Are you a new or returning patient? *

New

Returning

Required

Type of Appointment Requesting

Cleaning/Exam

X-rays

Sealant

Fluoride Treatment

Deep Cleaning

Other:

3. Dental History

Have you had Dental X-rays taken within the past 5 years?

Yes

Not sure

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When was your last dental cleaning? *

Do you need a periodontal cleaning (deep cleaning)?

Yes

Maybe

Clear selection

Have you received routine periodontal maintenance (deep cleaning) every 3-4 months as recommended by your dental provider?

Yes

Clear selection

Do you have a removable prosthesis (dentures, partials, retainers)?

Yes

Maybe

Do you have a removable prosthesis (dentures, partials, retainers)?

Would you like your removable prosthesis cleaned?

Clear selection

Would you like to get sealants?

Yes

Maybe

Clear selection

Pediatric-Specific Questions (Only if "Yes" to Pediatric Patient)

Has your child received fluoride treatment before?

Yes

Maybe

Clear selection

Does your child have dental anxiety? Is there anything we can do to help?

Yes

Other:

Clear selection

5. Medical

Do you have any of the following medical conditions? (Checkboxes, select all that apply)

Heart Disease or Heart murmur

High blood pressure

Diabetes (Type 1 or Type 2)

Asthma or breathing disorders

Blood disorders (Anemia, Hemophilia, etc.)

Kidney disease

Liver disease (Hepatitis, Cirrhosis, etc.)

Osteoporosis

Stroke or history of seizures

HIV/AIDS

Cancer or chemotherapy/radiation treatment

Autoimmune diseases (Lupus, Rheumatoid Arthritis, etc.)

Anxiety or mental health conditions

Other:

Are you currently taking any medications?

Yes

Clear selection

Do you currently smoke any tobacco products?How many cigarettes, cigars, or other tobacco products did you typically smoke per day?

Option 1

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Do you have any allergies (medications, latex, etc.)?

Yes

Clear selection

If yes, please list them:

Are you pregnant or nursing?

Yes

Not Applicable

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Do you require antibiotics before dental treatment? (For heart conditions, joint replacements, etc.)

Yes

Not sure

Clear selection

Confirmation & Submission *

"I understand that this is a request, and my appointment is not confirmed until I receive a confirmation call/email

Required

Thank you for scheduling an appointment at the Student Dental Hygiene Clinic at Concorde Career College – Portland, OR! 🦷

We truly appreciate your patience and support in this learning process. Your visit helps our students gain hands-on experience while providing you with quality dental care.

📞 Next Steps:

A student will review your request and contact you to confirm your appointment. Please allow time for scheduling, as appointments may require 2-4 visits, each lasting up to 3 hours.

If you have any questions, feel free to contact us. We look forward to seeing you soon!

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