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Patient Information

Patient Information

Eligibility Criteria

Must be an adult Waukesha County resident or live in the Oconomowoc School District at or below 200% of the Federal Poverty Level with no private insurance.

Registration

Please bring the following items with you:

ALL patients need to bring

  • Photo ID
  • Proof of residency in WAUKESHA COUNTY, such as a recent utility bill, paystub, lease

Medicaid Insured patients

  • Insurance card – If insurance card is not shown, the patient can NOT be seen for an appointment
  • Cash Only for co-payments 

Uninsured Patients

  • 2 most recent paystubs for ALL household members claimed on your taxes
  • 2016 tax information
  • Cash Only for payment before they are seen

 

Forms – Registration and Medical Information

2017 LAFC Dental Patient Registration
2017 LAFC Dental Medical History

2017 SPANISH LAFC Patient Registration
2017 SPANISH LAFC Medical History