   DENTAL CLINIC

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Screening Appointment List

This form will be active

Monday, August 4, 2008- Friday, August 8, 2008

Notice: This form is for adult patients only (ages 13 and older). For patients under the age of 13, please contact the Pediatric Dentistry department at (414) 288-7273.

Please complete the information below to be added to our waiting list.


† Required field

Title:

First Name: †

Middle Name:

Last Name: †

Address: †

Address 2:

City: †

State:

Zip Code: †

Date of Birth: † (mm/dd/yyyy)

E-mail: †

Daytime Phone Number: † (9:30am - 3:30pm)

Alternate Phone Number:
Please make sure that you have filled out the form correctly before you press Submit. YOU DO NOT NEED TO CALL TO CONFIRM YOUR REGISTRATION. Calling or submitting more than one online form will create a duplicate registration. A duplicate registration will result in the forfieture of your spot on the waiting list. By pressing Submit below you are confirming that the above information is correct. If you need to change your information after your initial registration, please do so with a registration attendant or with your student.

A registration attendant will contact you via email in approximately two weeks with additional information.