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Prospective Patient Form

Once you submit your completed Prospective Patient Form, your name will be placed in a database of potential patients. A representative from the OU College of Dentistry Communications Center will call you when a screening appointment becomes available. The educational needs of the students will determine the number of patients that we will screen and that need varies throughout the year.
 
Due to the clinical education mission of the school, completion of this screening form does not guarantee a screening appointment.
 
The fee for your initial screening is $28. A radiograph will be taken and you will be advised of your dental needs.
 
Although we cannot guarantee we can provide you with treatment, knowing and understanding your dental needs will assist you in making informed decisions about your dental care.
 
If you become a patient of record, you will be assigned to a student who will manage your oral health care.

As a rule, patients must agree to be available at least two (2) different half weekdays per month.
 
If you have questions, please call (405) 271-7744 for assistance.
 

Please complete the following information:

Contact Information

Contact Information

First Name * :
Last Name * :
Date of Birth * : (mm/dd/yyyy)
SSN:
Gender:

Address:
City:
State:
Zip Code:
Preferred Contact:

Daytime Phone^:
Cell Phone^:
Email Address^:
* - Required Fields ^ - One of these fields are required

Contact Information

Availability

What time would you be available for a screening appointment?
   
 
Mon
Tue
Wed
Thu
Fri
 
Morning
 
Afternoon
 

Contact Information

Current Dental Conditions

Which of the following conditions apply to you? Check all that apply:
   
I have cavities that need to be filled.
I have problems with my gums.
I have teeth that are loose.
I need tooth extractions.
I need root canal treatment.
I have a single missing tooth that needs to be replaced.
I have several missing teeth that need to be replaced.
I need caps or crowns for one or more teeth.
I have no teeth and I need dentures.
All my teeth are missing.
I am interested in braces.
I know or have been told that I have diabetes.
I have dental insurance I have Sooner Care I have Medicaid

I have previously been a patient at the College of Dentistry.

Please include any comments that will help us meet your needs as a patient.

Date Requested:

I agree to the terms and conditions listed above.

Copyright 2013 - OU College of Dentistry