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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 an assessment appointment becomes available if you meet the criteria for the educational needs of the students as a prospective patient.  The educational needs of the students will determine the number of patients that we will assess 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 an assessment appointment.


The fee for your initial assessment is $90.  An assessment exam will be performed and preliminary x-rays 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 are not accepted into the student program, we will provide you with a free summary report including copies of your x-rays and a list of your dental needs upon request.


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.


We are unable to accommodate adult Medicaid/SoonerCare patients.


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

Contact Information

Contact Information


LEGAL First Name * :
LEGAL 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

Program Requirements

I can afford at least $100 per appointment for dental care.
I have previously been a patient at the College of Dentistry.

I have reliable transportation to the College of Dentistry.

I have dental insurance other than Medicaid/SoonerCare.
I am eligible for Medicaid/SoonerCare.
Preferred Treatment Location * :

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.
I am interested in braces.

I only want to have my teeth cleaned.

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.


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