Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
For what service are you registering?
*
Please Select
Dental Bus (Exam, Extractions, Fillings, etc.)
Hygienist (Teeth Cleanings)
Please describe the dental problem you're having.
*
This information helps us serve you better when you arrive!
Dental Bus - Waitlist
Because of high interest in the dental bus services, the dentists and hygienists are fully booked. However, you're welcome to register in advance to be seen in the event that an appointment does not show. Please check the box below if you wish to come and wait for a first-come, first-served open slot in the case that an opening arises. Debido al alto interés en los servicios del autobús dental, los dentistas y los higienistas están completamente reservados. Sin embargo, puede registrarse con anticipación para ser atendido en caso de que alguien no se presente a su cita. Por favor, marque la casilla a continuación si desea venir y esperar por un turno disponible por orden de llegada, en caso de que se abra un espacio.
Please affirm the below statement:
*
Yes, I understand that the bus is currently booked, but am willing to wait for an opening if another appointment doesn't arrive. I understand that this does not guarantee I'll be seen. Sí, entiendo que el autobús está actualmente lleno, pero estoy dispuesto(a) a esperar por un espacio si alguna otra cita no se presenta. Entiendo que esto no garantiza que seré atendido(a).
Dental Bus Appointment
Hygienist Appointment
Pre-Register for Dental
Should be Empty: