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June 2025 Dental Appointment Request Form
*Please complete a registration form for each household member interested in a dental exam.* Our staff are using this form to contact patients as appointments are available throughout the month. At the end of the month, if you have not been contacted to schedule an appointment, you can register again during the next open scheduling period of the following month.
Patient Name
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Parent/Guardian Name (as applicable):
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Primary Phone Number
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Preferred Language
English
Spanish
Hmong
Other
Preferred Dental Clinic For Your Appointment (select all the apply):
Cashton
La Crosse
First Available Location
Additional Information/Special Instructions:
Dental Insurance
If you do not see your dental insurance company listed as an option below, it is likely that we do not have a dentist currently available for exams that is enrolled with that insurance. This means that your insurance will not pay for services from our dentists. This list may change in the future. No one will be denied access for lack of insurance.
Dental Insurance
*
Please Select
My insurance isn't listed
Uninsured
Medicaid/BadgerCare/Forward Health
Aetna
Ameritas
Anthem BC/BS
Federal BCBS
Careington Benefit Solutions
CIGNA
Connection/GEHA
Dental Benefit Prov/UHC PPO
Dental Blue (same as Anthem BC/BS) 300,200,100
SunLife Financial (formerly DHA/Assurant)
Delta Dental
Delta Medicare Advantage
DenteMax/AlwaysCare
Dentaquest
Guardian/Dental Guard
Met Life
Premier
Principal
UHC Dental Benefit Providers
United HealthCare Community Plan Medicaid/Medicare Plan
United Concordia
AFLAC Dental
American Public Life Ins Co
Foreign Service Benefit Plan
Vernon Mem. Dental Cypress
WEA Dental
RH Administrator
Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
This form is only available for submission on June 2 and June 3, 2025.
Submit
Should be Empty: