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Terms and Conditions

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 if you are accepted as a prospective patient.  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 Prospective Patient Form does not guarantee a screening appointment.


The fee for your initial screening is $29.  A radiograph will be taken and you will be advised of your dental needs and if you qualify for the Student Program.  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.  These appointments will be three (3) hours and will only be scheduled at 9am or 1pm, depending on your assigned student’s availability.  Cancelling or failing more than two appointments, could result in you being released from the program.  Payment is due at time of service and we do not offer payment plans.


If you have questions, please call 405-271-7744 for assistance.


Please complete the following information: (Are you in dental pain?)

Contact Information

Contact Information


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

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

Daytime Phone * :
Cell Phone:
Email Address:
* - Required Fields  

Contact Information


What times would you be available for an appointment?

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 can afford at least $100 per month for dental care.
I have dental insurance I have Sooner Care I have Medicaid
I have previously been a patient at the College of Dentistry.

I only want to have my teeth cleaned.

I have reliable transportation to 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 2015 - OU College of Dentistry