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Sign Up — I’m Interested in Dental Hygiene Services

Dental Hygiene Services
Tanecia DeDios (Student Dental Hygienist)
PIMA Medical Institute

Please provide your info & details to get scheduled, or if you would like more information.

*please keep in mind that your information is kept confidential and will only be viewed by the student for scheduling purposes
1.First and Last Name(Required.)
2.Birth Date(Required.)
3.Date of the last time you visited the dentist and reason(Required.)
4.Date of last dental cleaning(Required.)
5.Date of last dental X-rays and type or amount (bite wings with just the sides of the mouth/pano where the machine rotates around your head/multiple images taken on all teeth)(Required.)
6.Any medical conditions, diseases, or health concerns(Required.)
7.Do you take any medications or daily supplements?(Required.)
8.Contact Information (phone number, email, or both)(Required.)
9.Any other information that I would need to know:(Required.)