Dental Clinic Patient Intake Form
Please fill out all the required fields below.
First Name *
Last Name *
Email Address *:
Phone Number *
Academic Standing: * FreshmanSophomoreJuniorSenior
Which college/university do you attend? *
Amount of hours volunteered at Lubbock Impact: *
Hours shadowed/worked at a dental office: *
Dental office name/location: *
Registered Dental Assistant: * YesNo
If yes, license number:
Do you have your hepatitis B vaccine? * YesNo
If no, are you willing to sign a refusal form? YesNo
Verification of Enrollment *
Essay *
RDA license (if applicable)
Please allow the form time to upload your documents. Only click the "Submit" button once!.
2707 34TH STREET (34TH & BOSTON) LUBBOCK, TEXAS 79410
