Dental Studio
Coming to Waupun
New Patients
New Patient Forms
If it is convenient, you may bring in the following registration and health history forms filled out. You can bring them with your for your initial appointment. If you like, you may also fill them out in the waiting room prior to your appointment.
Please arrive 15 minutes prior to your scheduled time if all the paperwork has been filled out ahead of time. If you prefer to fill out the paperwork while in our office, please arrive 30 minutes prior to your appointment.
This "health history" helps us build a robust treatment plan which takes into account any relevant health events or circumstances.
Briefly, here is what the forms are for:
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The Welcome Pack forms and HIPPA Consent Form are to be filled out for all new patients.
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If an entire family or members of the family are becoming new patients, each new patient should have the forms completed.
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By signing the patient information form, you acknowledge that you have read and are aware of our privacy policy and how Dental Studio professionally manages your confidential and personal information. If you have any questions about our policies, please ask and we will be more than happy to explain.
FREE ORAL CANCER SCREENING at your New Patient Appointment! (adults only)
Forward Health Members
Please be aware that dental services covered by Forward Health may require co-payments *.
Co-pays must be paid at time of check-in. Please be prepared to pay up to $10.00 for each scheduled appointment per family member. We accept cash, checks and major credit cards.
Please bring your Forward Health insurance card along with you and please arrive 15 minutes before your scheduled appointment time to check-in.
Click Here to view our Sliding Fee Schedule
Discounted Special Services
Helping people who have nowhere to turn, alleviating someone's chronic pain, fixing a child's tooth so they aren't afraid to smile, and working with top notch, passionate dental providers -- these are the things that motivate us.
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Discounted Services Rate - Monetary discounted price based off of Federal Poverty Level Income Guidelines
ATTENTION
DENTAL SPECIAL SERVICES DISCOUNTS (Minimum of 5% down of total procedure before scheduled appointment)
Additional 5% Discount (if paid in full before initial procedure appointment) OR 6-month interest free payment plan signed by Patient.
IF patient fails to pay amount within the 6-month time period, patient will be taken off our scheduled patient list until fees are paid in full with an additional 5% of total fee added.
No Insurance? No Worries ...
Payments for main services if your earnings land within the 150% (or below) Income Level
$30.00 for a comprehensive exam (includes x-rays)
$35.00 for a prophylaxis appointment (cleaning)
$35.00 per tooth that needs filling
$40.00 per tooth that needs extraction
Monthly income that is over the 150% Income Level will be charged accordingly of the standard fee.
* Payment arrangements can be made with our Patient Financial Representative
CareCredit Financing
In addition, we offer the option of payment through CareCredit.
Care Credit has a comprehensive range of plan options, for treatment or procedure fees from $1 to over $25,000. Care Credit offers a plan and a low monthly payment to fit comfortably into almost every budget.