July 2026 Dental Appointment Request Form

July 2026 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.

Please note that once you establish care with a provider at one of our clinics, that provider will remain your primary provider for ongoing care. This approach supports continuity of care, ensures familiarity with your health history, and helps us deliver the best possible care experience. As a result, continuing treatment may require visits at the same clinic location where you initially established care.
What county do you live in?
Service Area Eligibility Notice

Thank you for your interest in a dental appointment at Scenic Bluffs. Unfortunately, your location falls outside our service area, and you do not qualify to register for a dental appointment. Our dental department currently only serves residents of Crawford, Grant, La Crosse, Monroe, Sauk, and Vernon counties only.
Patient Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Parent/Guardian Name (as applicable):

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / 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

EnglishSpanishHmongOther
Preferred Dental Clinic For Your Appointment (select all the apply): Please note that once you establish care with a provider at one of our clinics, that provider will remain your primary provider for ongoing care. This approach supports continuity of care, ensures familiarity with your health history, and helps us deliver the best possible care experience. As a result, continuing treatment may require visits at the same clinic location where you initially established care.

CashtonLa CrosseReedsburgFirst 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*
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
This form is only available for submission on July 1 and July 2, 2026.
Should be Empty:

July 2026 Dental Appointment Request Form

Service Area Eligibility Notice

Dental Insurance