Dental Hygiene Service Request

Dental Hygiene Appointment Request

Fox Valley Technical College Dental Hygiene Students Provide Dental Hygiene Services in a Clinical Setting

Students learn while the following services are performed:

The cost is $30.

When treatment is completed, a letter is written to share with your family dentist

For more information (920) 735-4884

Your Name*

First Name

Last Name

Your Date of Birth*

Phone Number (with area code)*

Can we text you at this phone number?*

Yes No

Email Address

Date of Last Dental Cleaning

Please let us know your availability for an appointment. After you submit this form, we will contact you to confirm an appointment time.

Appointment Availability

Appointment Availability
	Morning	Afternoon	Evening
Monday	Appointment Availability: Monday (Morning)	Monday (Afternoon)	Monday (Evening)
Tuesday	Tuesday (Morning)	Tuesday (Afternoon)	Tuesday (Evening)
Wednesday	Wednesday (Morning)	Wednesday (Afternoon)	Wednesday (Evening)
Thursday	Thursday (Morning)	Thursday (Afternoon)	Thursday (Evening)
Friday	Friday (Morning)	Friday (Afternoon)	Friday (Evening)