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

     

Patient Requirements and Registration Information

    


Requirements

 Patients must meet all three 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 (BaderCare)

Registration

 

·         Patients must register in person before being given an appointment.

·         Patients must bring proof of residence in one of the 3 counties such as a utility bill.

·         Patients must bring proof of family income - Forward Card (BadgerCare)or proof of family income (examples - last year's tax return, last 3 pay stubs, unemployment statement, social security statement.)

 





Important Information

  • CO-PAYS ARE REQUIRED AT EVERY APPOINTMENT AND MAY ONLY BE PAID IN CASH.
  • 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 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.

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.