Daily Hygiene Pre-Appointment Verification

Please Submit Completed Form to chrisad at the END of EVERY Day

MM slash DD slash YYYY
(This includes ALL patients having any/all types of procedures)
(PRIME TIME is VERY STRICTLY defined as WEEKDAY appointments that allow patients to leave after care before 8:30am...or allows them to arrive at 5:30pm or later. Also, any & all WEEKEND appointments are considered PRIME TIME.)
This field is for validation purposes and should be left unchanged.