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Patient Rules & Policies


  • I acknowledge that I have received a copy of MSW’s Notice of Privacy Practices.

  • I understand that is my responsibility to clarify if I have co-pays and balances prior to appointments

  • I understand that co-pays are due at the time of service unless other payment arrangements have been made in advance with MSW staff.


  • I understand that if my insurance denies my coverage I am responsible for the full costs of the treatment I received (will receive), at MSW as determined by sliding scale fees.

  • I understand that I am responsible for reporting phone number or address changes to MSW staff.


  • I understand that if I do not confirm an appointment 24 hours before or do not leave a message, that appointment could be cancelled by MSW due to extreme need and limited availability of dental appointments. 


  • I understand that if I fail twice to show up for general/hygiene appointments or once for a root canal without 24-hour notice to MSW, I will be discharged from the program and cannot reapply for one year (except in the case of an emergency).


  • I understand that if I fail to keep an appointment due to an emergency, I can bring in appropriate documentation which will keep me admitted into the program.

  • I understand that if I arrive more than 10 minutes late for an appointment without notifying MSW staff, my appointment will be marked as missed and I will not be seen that day.

  • I understand that MSW may use my information in order to apply for funding that supports the clinic.

  • I understand that I must conduct myself in a civil and respectful manner to MSW and Salvation Army staff. If I do not, I will be asked to leave the clinic and permanently discharged from the program.​


Call 608-665-2752


1320 Mendota Street
Suite 107

Madison, WI 53714


Call 608-665-2752

or E-mail:

Below is a copy of the More Smiles Wisconsin Dental Clinic Policies. This is part of our Patient Application (click to go to full application, and fill out prior to your appointment). 

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