Dental Hygienist Request Form

Thank you for requesting our services!
Please complete this form and we will respond within 24 hours of your submission.
*FOR EXISTING CLIENTS ONLY:  If you have an urgent request within the next 24 hours, please text the EMERGENCY business line:  402.202.0485

Question Title

* 1. Practice Name

Question Title

* 2. What is the Practice Address?

Question Title

* 3. Have we sent a Dental Hygiene Sub to your office before?

Question Title

* 4. Your Name (Individual authorized to submit requests on behalf of the practice).  
*If you are not authorized on this account, please submit to your practice representative (office manager, dentist, etc.)

Question Title

* 5. Enter EACH date and ALL hours of service requested.
Include the start time for first patient to end of day.   
(Example: 5/12/19 8a-5p)

Question Title

* 6. Other details / information regarding the request:

0 of 6 answered
 

T