Patient Application Form

PAtient Application Form

We appreciate your interest in becoming a patient at the Creighton Dental Clinic. To apply, please review our patient resources and then fill out the confidential form below, which will be kept on file for no more than six months. We’ll get back to you as soon as possible. Please note that completing this form does not guarantee an appointment. Questions? Please give us a call at 402.280.4080.

Availability for Assessment Appointment

Please select all weekdays and corresponding time periods during which you’re available for an assessment appointment. Not all time slots below are available year-round.

Dental Conditions:

Please select all conditions that apply. If you are not sure, see “Definitions of Conditions/Treatments” below.

If you would like to tell us more to help us understand your dental condition or special needs, please do so in the space provided.