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Dental Services 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 402.280.5990.

* = Required Fields

Full Name*

First Name*

Middle Name(s)

Last Name*

Generational (Jr., Sr., I, II, etc.)

Date of Birth*

Address

Home Address*

City*

State*

Zip Code*

Daytime Phone*

Cell Phone

Dental Conditions

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

I know or have been told that: *

I have cavities that need to be filled
I have gum problems
I have loose teeth
I need a tooth extraction
I need root canal treatment
I need caps or crowns for one more teeth
I have a single missing tooth that needs to be replaced
I have multiple missing teeth that need to be replaced
I need dentures
I have dentures but need to replace them
Other - explain below:

Please explain your "other" dental issues, or use this space to tell us more to help us understand your dental condition or special needs:

Definitions

Do you have insurance?

Name/phone number of Insurance Company:

Group Number:

Subscriber Number:

2500 California Plaza
Omaha, NE 68178
402.280.2700
creighton.edu