Dental Hygiene Clinic Appointment Reservation

Appointments are for preventive services ONLY
*Screenings are required for all new patients and patients that haven't visited the clinic in the last 3 years
**We always refer patients to see a general dentist after visiting our clinic

Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Phone Phone - ### - ### ####
Email
Please Choose One:

Please Choose One: New patient (or if over 3 years since last visit to clinic) Returning patient (within the last 3 years)
When was your last dental cleaning?

When was your last dental cleaning? 2 years or less 3-5 years 5+ years