
Are there patient forms I can fill out before my visit?
- Child Registration Form (English)
- Child Registration Form (Spanish)
- Adult Registration Form (English)
- Adult Registration Form (Spanish)
- Medical Dental History Form (English)
- Medical Dental History Form (Spanish)
- Acknowledgement of Privacy Practices (English)
- Acknowledgement of Privacy Practices (Spanish)
- Consent of Minor (English)
- Consent of Minor (Spanish)
- Uninsured Patient Application (English)
- Uninsured Patient Application (Spanish)
What is the referral process?
- Please complete the Agency Referral Form. Provide as much information about the patient as possible.
- Fax referral form to our Waukesha clinic at fax number 262-522-2828 OR our Menomonee Falls at fax Number 262-502-0508.
- For all questions pertaining to a referral, please call the clinic you faxed your referral to.
- Patients will be scheduled for appointments by the Community Smiles Dental staff after eligibility is confirmed.
- OB/GYN medical providers should use our OB/GYN Referral Form. to refer pregnant patients to our clinics
Updated Sliding Fee Scale for Uninsured Patients 2025
2025 CSD Patient Letter – Updated Sliding Fee Scale (English)
2025 CSD Patient Letter – Updated Sliding Fee Scale (Spanish)
To make an appointment, please call the clinic at 262-522-7645.
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