Dr. Beth Salonek & Dr. Karyn Kartje

235 W Prairie View Road | Chippewa Falls, WI 54729 | 715.720.9125

New Patients

 

Welcome to our office!

 

For each new patient, please fill out, print and bring the following forms with you to your first appointment.

 

We can also mail forms to you if you'd prefer. Please call our office to make arrangements.

 

If you are unable to do so, please arrive 15 minutes prior to your appointment to fill out the necessary paperwork.

 

 

 

Forms

Patient Information Form

 

Dental History Form

 

Medical History Form

 

 

The following form is optional to print and is for your reference only.

 

Updated Notice of Privacy Practices

 

Updated Notice of Privacy Practices (en español)

 

 

Thank you. We look forward to meeting you and welcoming you into our dental family.

 

 

Financial Information

 

Here at NorthPark Dental, we highly appreciate the emotional and financial investment to proceed with comprehensive dentistry. During your consultation, our doctors and staff will review your treatment plan with you and provide a description of the proposed treatment. We will also discuss your investment prior to any treatment, along with several options for your convenience.

 

We can help you maximize your benefits: We accept most dental insurance programs used by major employers in our area. Our goal is to maximize your insurance benefits and make any remaining balance due easily affordable.

 

We Accept: In addition to cash, we accept checks, VISA, MasterCard and Discover. We also work with third party financing companies to make it easy to get your treatment now and pay for it over a period of time. We will try to find a financial arrangement that works for you.