Web Contact Form Template

Pierce College Dental Hygiene

Patient Appointment Request Form & Process
Screening exams (free) are required before scheduling a preventive or restorative treatment appointment. We want to be certain our clinic can meet your individual dental needs. This appointment takes about an hour.

If you qualify for treatment in our clinic, a Dental Hygiene Student will contact you personally to schedule your first treatment appointment. This will include a comprehensive exam and as needed, x-rays.

The Dental Hygiene Student provides all treatment under the close supervision of our expert licensed dental hygienists and dentists!
Name
E-Mail
Phone Number
Format: (000) 000-0000.
What is your preferred method of contact? Phone call, text, or email?

Phone CallTextEmail
When was the last time you saw a dentist or dental hygienist?
Do you have Apple Health Insurance, or are you Military, Veteran, or current Pierce College student?

YesNo
Do you have any physical/intellectual accommodations we need to be aware of?

YesNo
Any other items you want us to know prior to your appointment?
Limits of our Clinic:

We do not offer Tooth Extractions, Dentures, Crowns or Emergency Dental Treatment. Please contact the Pierce County Dental Society for a referral to a location that can provide these services. Website: PC Dentists Referral Link Phone: (253) 274-9722
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Pierce College Dental Hygiene