We thank you for your time spent taking this survey.

Your response has been recorded.

Below is a summary of your responses Download PDF

Thank you for your interest in becoming a patient at the University of Tennessee Health Science Center
(UTHSC) College of Dentistry. In order to identify your dental needs, please fill out the brief
questionnaire below as completely as possible. All information received will remain confidential.

First Name

vicki

Last Name

podczervinski

Date of Birth (mm/dd/yyyy)

06/18/1982

Address

2134 ptarmigan trl

City

memphis

State

tn

US Zip Code

38134

Contact Phone Number

6156053733
Contact Email

vickiepodczervinski@gmail.com

Screening Appointment Times

Please choose the days and times you will be available
for a screening appointment.
AM (morning) PM (afternoon)

Monday

Tuesday

Wednesday

Thursday

Friday

Conditions
Which of the following conditions apply to you? Check all that apply. I know, or have been told that:
I have cavities that need to be filled

I have problems with my gums

I have teeth that are loose

I need tooth extractions

I need root canal treatment

I have a single missing tooth that needs to be replaced

I have several missing teeth that need to be replaced

I need caps or crowns for one or more teeth

I have no teeth and I need dentures

All my teeth are missing

I'm interested in Orthodontics (braces)

Important
Before submitting this form be sure to read the Patient Information Booklet and Privacy Notice. Soon
after submitting this form a student doctor or a Patient Care Representative will contact you to discuss a
Screening Appointment. If you are scheduled, we ask that you arrive 30 minutes early. You can save time
by completing the Patient Information Form to bring to the appointment.

On the day of your appointment you will also need a Photo ID and payment (cash, major credit card or
personal check) to cover the screening fee. Screening Appointments require 3 to 4 hours of your time.
Other Comments
If you have any other comments, please enter them in the box below:

We are able to accept many people as patients. However, if we have several people on our waiting list or
if the care you need is too difficult for a student doctor we will suggest another clinic or refer you to a
private dentist.