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)
Please choose the days and times you will be available for a screening appointment.
Which of the following conditions apply to you? Check all that apply.
I know, or have been told that:
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.
If you have any other comments, please enter them in the box below:
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.
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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C-209 Dunn Building
Memphis, Tennessee 38163
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