Patient name:__________________



For clinic use – must be completed for each patient and turned into scheduling clerk

Patient name:__________________

Procedure:_____________________

Date needed:___________________

(if blank, then first available slot)

Time needed:

( Walk-in – 15 minutes

( 30 min.

( 45 min.

(1 hour

(1 ½ hrs

With: Dentist Dental Hygienist

Give to patient

Appointment time:

___________________________

Day Date Time

No appointments available

Call back for an appointment on:______ Date

For clinic use – must be completed for each patient and turned into scheduling clerk

Patient name:__________________

Procedure:_____________________

Date needed:___________________

(if blank, then first available slot)

Time needed:

( Walk-in – 15 minutes

( 30 min.

( 45 min.

(1 hour

(1 ½ hrs

With: Dentist Dental Hygienist

Give to patient

Appointment time:

___________________________

Day Date Time

No appointments available

Call back for an appointment on:______ Date

For clinic use – must be completed for each patient and turned into scheduling clerk

Patient name:__________________

Procedure:_____________________

Date needed:___________________

(if blank, then first available slot)

Time needed:

( Walk-in – 15 minutes

( 30 min.

( 45 min.

(1 hour

(1 ½ hrs

With: Dentist Dental Hygienist

Give to patient

Appointment time:

___________________________

Day Date Time

No appointments available

Call back for an appointment on:______ Date

For clinic use – must be completed for each patient and turned into scheduling clerk

Patient name:__________________

Procedure:_____________________

Date needed:___________________

(if blank, then first available slot)

Time needed:

( Walk-in – 15 minutes

( 30 min.

( 45 min.

(1 hour

(1 ½ hrs

With: Dentist Dental Hygienist

Give to patient

Appointment time:

___________________________

Day Date Time

No appointments available

Call back for an appointment on:______ Date

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