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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)
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Madison Family Dental

4.9 - 112 Google Reviews

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Camille Cowan4/20/2019

I haven't been to the dentist in many years since he retired. I did my research when finally looking for a dentist place. Madison Family Dental is a great fit. They weren't shocked or judgemental about how long it had been since my last cleaning and they were also respectful.

Becky Hay De Garcia8/20/2019

Dr. Challenger and his team of hygienists are extremely competent and more honest than any dentist I have seen since the 80s. If he discovers a possible issue, he tells the patient what he sees, explains that it may not become a problem for a week or many years, and allows the patient to decide whether to just watch that tooth/area or get it fixed right away. Before I switched to Dr. Challenger, I was told by my dentist that I needed 4 crowns. That was over 10 years ago. Dr. Challenger found no such problems, but after a few years he saw one tooth that needed watching. It was several years later that I actually needed a crown on that tooth. I have never needed another. On Monday this week, I had my teeth cleaned, and Dr. Challenger discovered that a small piece of one of my very old fillings had broken off. I was able to get an appointment the VERY NEXT DAY, to have it replaced!

Tom Scott9/20/2018

I think my wife and I have been patients of Dr. Challenger since he began his carer with Madison Family Dental. Throughout that lengthy period we have been the satisfied recipients of excellent and caring dental care. We've been welcomed by name, made comfortable during our brief wait times, and the staff are even kind enough to laugh at my occasional jokes. In all the years we've obtained our dental care from Madison Family Dental we've never questioned and never doubted that we were in good hands from the reception staff, to the business office, to the hygienists, and the docs. This is a great place.

Paul Hickman1/14/2020

Dr. Challenger is fantastic. All aspects of working with Madison Family Dental is smooth and simple!

Marcy Garrison9/20/2018

Dr. Veerman is the finest I have ever had. The dental work I have had done is flawless. And her hygienist Michelle is a friendly professional who also is very conscientious about her work. I would recommend Madison Family Dental to anyone looking for the best!!!