Back
Appointment Request Summer 2025
Fones Dental Hygiene Health Center
60 Lafayette Street
Bridgeport, CT 06604
203-576-4137
First Name
Last Name
Phone #
Email Address
Date Of Birth
Reason For The Visit
Preferred time of appointment:
Preferred day of the week (select all appropriate)
Please check below ONLY if you request a Spanish speaking intern. This request will be considered but can not be guaranteed.
Are you a new or existing patient?
Are you a HUSKY Client?
Are you 65 or over and reside in Greater New Haven or Greater Bridgeport?
Are you a current UB student?
If a specific student intern is requested, please add name below.
Please tell us how you heard about us or provide any additional comments below.
Fones School of Dental Hygiene is a teaching institution. Its main purposes are to educate and graduate qualified dental hygienists. Preventive and periodontal services at the School will exceed the length of time for the same services in private practice.
Patient must plan to stay for the entire clinic session and must expect to require several clinic sessions based on the complexity of their dental hygiene needs.
Signature
Sign Here
×
Signature Pad
Back
Next
Back
Next
Submit
Done