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Madison 608.274.5970
DeForest 608.846.3302

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PAY MY BILL REQUEST APPOINTMENT

Madison
608.274.5970

DeForest
608.846.3302

PAY MY BILL REQUEST APPOINTMENT

Madison | DeForest

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Periodontal Referral Form

Patient Information
Patient Name*
First Last
Primary Phone*
Secondary Phone
Preferred Clinic*
- DeForest
- Madison
Birthday*
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DD
YYYY
Referred By
Doctor*
Clinic*
Phone*
Email*
Requested Services
Periodontal Therapy
- Comprehensive Exam & Treatment
- Limited Exam & Treatment
- Crown Lengthening
- Gingivectomy
- Soft Tissue Grafting
- Pocket Reduction
- Periodontal Bone Grafting
- Other Periodontal Therapy
Limited Exam & Treatment - Tooth Number(s)*
Crown Lengthening - Tooth Number(s)*
Gingivectomy - Tooth Number(s)*
Soft Tissue Grafting - Tooth Number(s)*
Pocket Reduction - Tooth Number(s)*
Periodontal Bone Grafting - Tooth Number(s)*
Other Periodontal Therapy*
Implant Therapy
- Extraction & Site Preservation
- Implant Placement
- Immediate Implant Placement & Provisional Crown
- Sinus Augmentation
- Ridge Augmentation
- Other Implant Therapy
Extraction & Site Preservation - Tooth Number(s)*
Implant Placement - Sites:*
Immediate Implant Placement & Provisional Crown - Sites:*
Sinus Augmentation - Tooth Number(s)*
Ridge Augmentation - Tooth Number(s)*
Other Implant Therapy*
Other Services
- Extractions
- Prosthetic Surgery
- Soft/Hard Tissue Biopsy
- Tooth Exposure for Orthodontics
- Frenectomy
- Orthodontic Mini Implants
- Fiber Release
- Other Services
Extractions - Tooth Number(s)*
Pre-Proshetic Surgery - Tooth Number(s)*
Soft/Hard Tissue Biopsy - Tooth Number(s)*
Tooth Exposure for Orthodontics - Tooth Number(s)*
Frenectomy - Tooth Number(s)*
Orthodontic Mini Implants - Tooth Number(s)*
Fiber Release - Tooth Number(s)*
Other Services*
Recent Full Mouth Radiographs (within 3-5 years)*
- Patient will bring
- File attached below
- Mailed to office
- New Radiographs Needed
More Details or Comments
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File Attachment (Radiographs or other)
File Attachment (Radiographs or other)
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Please request an appointment online for a dental treatment consultation with one of our dental professionals.

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Our Services

General Dentistry

Restorative Dentistry

Geriatric Dentistry

Pediatric Dentistry

Periodontal Dentistry

Snoring & Sleep Apnea

Cosmetic Dentistry

Orthodontics and Invisalign

Tooth Extraction

Dental Implants

TMJ Disorder Treatment

Madison
5709 Odana Road, Madison, WI 53719
Phone: 608-274-5970
Mon – Thurs: 7 am – 7 pm
Friday: 7 am – 4 pm

DeForest
502 Nelson Court, DeForest, WI 53532
Phone: 608-846-3302

Monday: 8 am – 5 pm
Tuesday: 7 am – 4 pm
Wednesday: 10 am – 7 pm
Thursday: 8 am – 5 pm
Friday: 8 am – 4 pm

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Madison Family Dental Associates

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Madison Family Dental

4.8 - 121 Google Reviews

Levi Hagen4/20/2019

Great experience. I'm always treated the way I'd hope to be treated. Great staff. Bessie and Dr Wirtz are excellent. I've been a patient for ~10 years.

PATRICK ROSEBOOM8/22/2019

Have been taking care of my teeth from at least 15 years. Do an excellent job of addressing my concerns. Cleanings with Bessie are always done gently and Dr. Wirtz is very efficient and careful when giving me filings or crowns.

James Rossing6/20/2019

Dr. Wirtz and Tayler are incredible. Provide the best care and always make you feel welcome!

Evelyn Beran9/20/2018

I recently had surgery which required me to postpone my hygiene appointment for several weeks. Barb was wonderful in working me in for a new appointment and she and Dr. Heim did a great job of checking things over to be sure no damage had been done during surgery and explaining things to me.

Tim Fraley9/25/2019

Excellant from Check in to leaving. Dr. Heim explianed every thing along the way. I knew the risks as we proceeded. Quick Work. Once again an excelolant visit