Appleton
9 Tri-Park Way
Appleton, WI 54914-1661
920-882-5500

Patient Requirements and Registration Information


 

Requirements

 

         Individuals must live in Calumet, Outagamie, or Winnebago County. 

 

          Individuals must have NO dental insurance.

 

          Individuals must have family income below 200% of federal poverty level or a Forward Card (Badger Care)

 

 

Registration

         Patients must register in person before being given an appointment.

          Patients must bring proof of residence in one of the three counties (Calumet, Outagamie, or Winnebago) such as

  • Driver's License
  • Utility Bill
  • Cable Bill
  • lease

          Patients must  bring proof of family income  such as (Bring all that apply)

  • Food Share
  • Social Security and SSI
  • Wages from job
  • Unemployment/Worker's Compensation
  • Pension
  • Lasy year's W2 or 1099
  • Child Support





Important Dental Care Information

  • CO-PAYS ARE REQUIRED AT EVERY APPOINTMENT AND MAY BE ONLY PAID IN CASH OR CREDIT CARD.
  • You will be required to make a co-payment based on a sliding scale according to your income.  The maximum co-payment for a regular dental care appointment will be $25.00.
  • Bring proof of your family income and residence if you have not been seen at the clinic in the past 3 months.
  • Arrive 15 minutes early to each appointment to fill out necessary paperwork.
  • If you miss an appointment, you will not be seen for six months.
  • Care may be provided  by Marquette University School of Dentistry dental students or a Fox Valley Technical College dental hygiene student under the supervision of one of our local volunteer dentists.

Denitstry for Children

  • Children under 18 must be accompanied by a parent or legal guardian at every appointment.
  • Children must be supervised in the waiting area.
  • Children not receiving treatment must remain in the waiting area.  They may not accompany an adult or other child in the treatment room.