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Madison | DeForest | Appointment Request

Dentist Referral Form for New Patients

Patient Information
Patient Name*
First Last
Name of Parent/Guardian if Patient is a Minor
First Last
Primary Phone*
Birthday*
Date Format: MM slash DD slash YYYY
Preferred Clinic*
- DeForest
- Madison
Referred By
Doctor*
Clinic*
Phone*
Email*
Patient Information
Date of Last Exam*
Date Format: MM slash DD slash YYYY
Date of Last Cleaning*
Date Format: MM slash DD slash YYYY
Date of Most Recent Bitewings*
Date Format: MM slash DD slash YYYY
Date of Most Recent Panoramic/Full Mouth Series of X-Rays*
Date Format: MM slash DD slash YYYY
File Attachment (X-Rays, Notes, Letters or Other)
More Details or Comments
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Please request an appointment online for a dental treatment consultation with one of our dental professionals.

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ONLINE PAYMENTS

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David Hall4/10/2021

Dr Wirtz and staff are always helpful, courteous and professional. I've been a patient for years and never fail to be impressed by the service and care they provide. I am away from Madison much of the time but always return to MFD for my dental needs. Thanks.

Karen Rogers3/26/2021

I was impressed with the time every staff member and Dentist provided to me during my two visits. They were professional , courteous, kind and caring.
There were explanations given for the crowns that had to be done.
I also liked the massage given to my upper back while they were working on my teeth.
Once again, my visit on March 24 was pleasant. Every staff member and dentist were kind, caring and professional.

Kirsten Bushek1/20/2019

I have only been to a few dentists (I spent many years with one before he retired!) and had some anxiety about finding a new dentist. Would their work be excellent? Would they be gentle? Would they be nice? How are their assessment skills? Ashlee and Dr. Julian checked all these boxes with excellent for both myself and my husband. I am so happy with the entire experience. From being greeted at the front desk, to a quick escort back, the chair-side service and meeting my concerns and expectations... They did everything superbly. I am so happy I established care here and am excited to continue to be a patient here.

Natalia Solodin4/03/2019

This clinic is wonderful!All staff is very friendly and helpful. They have a shifted schedule, so you can set up an appointment at any time of the day for your convenience.During my last visit, Dr.Challenger and his supporting hygienist Doris both did a great job as always. My all questions were answered, and theyr recommendations were very helpful..

Anna Garcia3/20/2019

Everyone that works here is very welcoming from the moment you walk in the door. My entire family has been going here for three years. Our hygienist Lindsey is so kind and gentle which makes it a piece of cake for our six year old to get her teeth cleaned. Dr. Donnelly is like seeing an old friend, he is always on top of all the activities that our fmaily is up to.