Free Dental Cleanings at Portland Community College (PCC) 
Hi, my name is Nancy! I am a dental hygiene student at PCC and I am searching for patients who are in need of free dental cleanings or dental care. My school's clinic offers all services for free! This includes services like x-rays, dental exams, etc. All ages and backgrounds are welcome (: 

Please answer the following questions below for consideration. The questions below help me determine if I am able to take you on as a patient this school term. 

After you submit this form, I will contact you to discuss about booking an appointment. Thank you for your time and consideration! 
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What is your name and pronouns? *
When was your last dental cleaning? *
Do you have have dental anxiety? If so, that is okay! we can work together to make you feel comfortable :)
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Do you have any medical conditions or anything I should know about your health? (The more I know, the more I can provide better care for you.) *
If you're comfortable with sharing, Please describe your current at home dental care routine? For example: Toothbrushing, mouth products, flossing? 
Since this is an educational environment, appointments are 3 and a half hours long and may take multiple appointments (about 2-3 visits). 

Are you able to commit? 

*No shows and late arrivals will affect me as a student with grade deductions!*
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If I am unavailable to see you this term, would you like me to save your contact information to reach out to you in the future?  *
PCC's clinic is located in Downtown Portland on SW 5th Ave. Are you able to access this location? *
Which appointment time and days work best for you? *
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What is your phone number? *
What is your email? *
What is your preferred way for me to reach out to you?  *
Do you have any questions, concerns or comments?
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