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Patient Application Form

Thank you for your interest in becoming a patient at the Creighton University School of Dentistry. Please fill out the requested information in the form below, including contact information, availability, and your dental needs. All information received will remain confidential. The fee for the initial Assessment appointment is $66 for dental X-rays.

If you are in pain or have a dental emergency, please call the Acute Care Clinic at 402-280-4080 for an emergency appointment.

Contact Information
Assessment Appointment

Please choose the days and mornings or afternoons you will available for an assessment appointment.

Dental Conditions

Which of the following conditions apply to you? Check all that apply. Click on the links below for information regarding these dental conditions.

Important Information
  • This application will be kept on file for a period of six months. During that time, you may be contacted for an assessment appointment. If you become a patient of record, you will be assigned to a student who will manage your comprehensive oral health care.
  • Due to the clinical education mission of the school, completion of this form does not guarantee an appointment. If you have questions, please call 402-280-4080.
  • Please print and fill-out the Patient Registration/Health History Form and bring it in for your appointment.
Your Comments
Information for Patients

Before submitting this application form, please read the Patient Resources. If you have other questions, please review the information in Frequently Asked Questions.

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