JCCC Dental Hygiene Appointment Request Form

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JCCC Dental Hygiene Clinic

Appointment Request Form

SAFETY GUIDELINES

Review our our Daily Wellness Check prior to visiting the JCCC campus.
Minors may only be accompanied by one adult.
If you have a special dental or medical condition, we may need a written statement from your physician prior to treating you. This will be determined during your initial consultation.

ABOUT PATIENT

Patient Status:

First Visit

Returning Visit

Patient First Name:

Patient Last Name:

Patient's Date of Birth:

Contact Name (if different than patient name):

First Name:

Last Name:

Email Address:

Phone Number:

Is that number a ...

Cell phone

Land line

Preferred mode of communication:

Phone

DENTAL HISTORY

Date of last professional cleaning (approximate):

Date of last X-rays (approximate):

Do you have a special dental or medical condition?

Yes

JCCC dental hygiene appointments last 3.5 hours, and it could take multiple appointments depending on your oral health needs and the skill level of the student.

SPRING - Appointments are scheduled late January through mid-May.
SUMMER - Clinic is closed late May through late August.
FALL - Appointments are scheduled late August to early December.
WINTER - Clinic is closed early December through late January.

What times and days of the week are you available for appointments?

Mondays

Tuesdays

Mornings: 8-11:30 a.m.

Afternoons: 1-4:30 p.m.

Wednesdays

Thursdays

Mornings: 8-11:30 a.m.

Afternoons: 1-4:30 p.m.

Are you available for last-minute cancellation appointments?

Yes

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