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Patient Appointment Request Form





Good Neighbor Dental Clinic
Call on Monday mornings at 8:30 To schedule appointments
277 West Gray Houston, Tx, 77019
713 529-3260
Greater Houston Dental Society
Makes referrals to low cost clinics
1 Greenway Plaza #110 Houston, TX 77044
713 961-4337
Harris County Hospital District/Dental Center 
Must have a Gold Card
5230 Griggs Rd. Houston, TX 77021
713 526-4243
San Jose Clinic 
301 Hamilton Houston, TX 77002
713 228-5528
University Dental Center at Hermann Hospital 
Fees are closer to private practice
6410 Fanning, Suite 310 Houston, TX 77030
713-486-5888
University of Texas Pediatric Clinic 
6 to 11 year olds 1st floor
7500 Cambridge St, Houston, TX 77054
713-486-4334
City Of Houston Dental Bureau 
Children only
80000 N. Stadium Dr Houston, TX 77054
713 794-9363
Healthcare for the Homeless 
2505 Fannin
Must have a letter stating you are homeless
Services included (Cleaning, extractions, Root Canal Crowns, Bridge and Partials)
713 739-7752 ext 130




This form is a request for a dental assessment appointment for adults and children over 13 years of age.  The assessment appointment will help match the needs of the many applicants who seek treatment with the academic needs of our students and residents. You will be contacted for an assessment appointment if you qualify.

The Assessment Clinic is closed from May 8th until June 2nd. Applicants will be called beginning May 26th to set appointments for the summer session.

Patient Information

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Symptoms
  • Are you experiencing dental pain? *    
  • Do you have more than 5 caps or crowns? *   
  • Do you wear dentures and need new ones? *  
  • Are you missing more than 2 or 3 teeth, not counting wisdom teeth? If the answer is NO, please proceed to question 6 and complete the request. *    
  • If the answer to Question 4 is YES, do you need all remaining teeth extracted?  If the answer is YES, please proceed with request.  If the answer is NO, our dental students cannot treat you at this time. *     
  • What are your chief complaints?  Check all that apply. *
    • Decayed teeth
    • Bleeding gums
    • Broken or chipped tooth or teeth
    • Missing teeth
    • Other