Horry Georgetown Technical College
Dental Hygiene Clinic
Availability and Short Notice List
Thank you for entrusting our clinic with your dental hygiene needs. The American Dental Association recommends
professional dental cleanings at least once every six months. Unfortunately, due to the nature of HGTC’s student
services we are unable to ensure that our patients will be seen twice annually. We do suggest that you alternate your
dental cleanings between our clinic and a local dentist. If your work/home/ or school schedule allows for us to contact
you on short notice, to fill in for an appointment cancelation, please complete this form.
Because of the volume of people we serve, it is encouraged to periodically check on the status of our waiting list. We do
provide our students with return patients’ contact information however students are limited to the amount of patients
they will see in a given semester.
NAME:_________________________________________________________________ Today’s Date:______________
City: ___________________________________ _______________________________ Date of Birth:______________
Cell Phone: ___________________________________ Home Phone:________________________________________
Email:________________________________________________ Do you check your email often:_________________
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We do attempt to give patients as much notice as possible, however, often times, we do not have much notice of a
cancelation. Please indicate below your personal flexibility so we may contact you when it is generally most
convenient for you to come in on short notice. REMINDER: TYPICALLY, APPOINTMENTS ARE 3 ½ HOURS LONG.
Days/Times Most Likely available (please check all that apply to your availability -scheduled days subject to change)
SUMMER DAYS (rising senior students)
FALL and SPRING DAYS (senior students)
___Mon. am
___Mon. pm
___Tues. am
___Tues. pm
___Wed. am
____ Wed. pm
___Thurs. am
___Thurs. pm
 Good To Go
Not much notice is needed
to fill for a last minute
cancelation or no show.
 1-2 hours
Needs 1-2 hour notice to
arrange daycare, make
arrangements at work, etc.
 Few hours
Live more than 45 minutes
away, need time to
coordinate their schedule.
(ie: call in am for pm appt)
 Day Before
Notice of appointment one
or more days before as it
best works for them to have
a little bit of notice.
Other considerations
 Early Bird. I am generally awake before 8 am. Please feel free to contact me in the morning for either a
morning or afternoon appointment that is available due to a cancelation
 I have youngsters in school. Morning appointments are best for me.
Additional considerations (use reverse side for more space)
____________________________________________________________________________________________________________
________________________________________________________________________
Have you ever been advised to antibiotics prior to dental cleaning? (ie: do you have any joint or heart valve
replacements or do you have a history of a heart murmur.) ____YES
_____NO If yes, why?_________________
It is suggested that all patient candidates contact HGTC Clinic if they have not been called in for an appointment. HGTC Dental Clinic monitors patients’ interest and your follow-up does
improve your chances of being called for an appointment. Being on our waiting list or short notice list does not guarantee an appointment. Please contact the appointment desk at 843839-1070 to determine likelihood of being contacted based on candidate volume.
Mail to: HGTC, Attn: Dental Sciences, PO Box 261966, Conway, SC 29528
or email a scanned copy of your completed information to noelle.whittaker@hgtc.edu