Milwaukee County Dental Access Directory

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* 1. Dental Clinic Name

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* 2. Address of Clinic

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

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* 3. Hours of Dental Clinic

Days of week and hours

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* 4. Dental Services Provided

Prevention services

General restorative

Endodontics

Oral surgery

Periodontics

Pediatrics

Other (please specify)

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* 5. Special populations served

Pediatrics

Pregnant women

Differently abled

Homeless

Adults only

All ages

Other (please specify)

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* 6. Payer Population

Medicaid/Badger Care

Uninsured

Commercial insurance

Other (please specify)

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* 7. Required Documents

Insurance card (if applicable)

Proof of income

Photo identification

Medical history

Co-pays (if applicable)

Other (please specify)

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* 8. Payment practices

Self-pay

Sliding fee scale

Clinic bills 3rd party payer

Free to all eligible patients

Other (please specify)

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* 9. Languages

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* 10. Contact Information

Name

Email Address

Phone Number