ATSU Student Appointment Request Form

Schedule Patient Appointments
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This appointment request form is for scheduling appointments for patients that you have communicated with outside of clinic. Please make sure you check your schedule to ensure you are free at the time you are requesting the appointment for the patient and the patient has confirmed with you that it will be a good time for them to see you in the clinic.

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Student provider name*
(enter your name)
 
 
 
Student provider email*
(enter your ATSU email address, used to receive confirmation that your appointment has been scheduled)
 
 
 
Patient last name*
(enter the last name of the patient you would like to schedule)
 
 
 
Patient first name*
(enter the first name of the patient you would like to schedule)
 
 
 
Type of request*
(is this an urgent request, meaning a request that needs to be completed within 24-hours)
Appointment date*
(enter the date you would like to schedule the patient)
Date
 
 
 
Appointment time*
(enter the time you would like to schedule the patient)
Time
 
 
 
:
 
 
 
Appointment length*
(enter the amount of time you would like to book for this appointment)
 
 
 
Procedure to be scheduled*
(enter a description of what treatment you will be performing)
 
 
 
Tooth number*
(enter the tooth number(s) you will be working on)
 
 
 
Notes
(please enter any notes you wish to convey to the person who will be booking the appointment in Dentrix on your behalf)
 
 
 
 
 
Submit
 
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This form was created inside of Triton Medical Solutions.

TRITON MEDICAL SOLUTIONS

Physical Address: Kyrene Corporate Center | 9280 South Kyrene Road | Suite 112 | Tempe AZ 85284-2954
Mailing Address: PO Box 13606 | Tempe AZ 85284-0061
Phone: (602) 457-7320 | Fax: (866) 467-4430