College of Dentistry Patient Application Form

Thank you for your interest in becoming a patient at the University of Tennessee Health Science Center (UTHSC) College of Dentistry. In order to identify your dental needs, please fill out the brief questionnaire below as completely as possible. All information received will remain confidential.

First Name: Last Name:

Date of Birth: (mm/dd/yyyy)

Address:

City: State: Zip:

Home Phone:

Cell Phone:

E-mail:

Screening Appointment

Please choose the days and times you will be available for a screening appointment.

Monday

  • AM
  • PM

Tuesday

  • AM
  • PM

Wednesday

  • AM
  • PM

Thursday

  • AM
  • PM

Friday

  • AM
  • PM

Conditions

Which of the following conditions apply to you? Check all that apply.
I know, or have been told that:

Important

Before submitting this form be sure to read the Patient Information Booklet and Privacy Notice. Soon after submitting this form a student doctor or a Patient Care Representative will contact you to discuss a Screening Appointment. If you are scheduled, we ask that you arrive 30 minutes early. You can save time by completing the Patient Information Form to bring to the appointment.

On the day of your appointment you will also need a Photo ID and payment (cash, major credit card or personal check) to cover the screening fee. Screening Appointments require 3 to 4 hours of your time.

Other Comments

If you have any other comments, please enter them in the box below:

2000 characters left

We are able to accept many people as patients. However, if we have several people on our waiting list or if the care you need is too difficult for a student doctor we will suggest another clinic or refer you to a private dentist.

Final Step

To complete the submission of your patient application form, in the space provided below, please type in the 2 words pictured, then click the "Submit" button. Thank you for your submission.

    

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Contact Us

Patient Care General Information

875 Union Avenue
C-209 Dunn Building
Memphis, Tennessee 38163
Phone: 901-448-6468
Fax: 901-448-2671