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Madison 608.274.5970
DeForest 608.846.3302

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Madison | DeForest | Appointment Request

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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
File Attachment (Radiographs or other)
File Attachment (Radiographs or other)
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: 8 am – 5 pm
Thursday: 8 am – 5 pm
Friday: Closed

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Madison Family Dental Associates

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Madison Family Dental

4.9 - 154 Google Reviews

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joyce Bringe1/06/2021

Excellent service

Randall Erb9/20/2018

Dr. Julian-Hoernke has been my dentist for over 10 years. Time passes so swiftly I can't give an exact length of time but I can say that she is very very good, as are all the individuals on her team. I would like to give kudos to each team member but my memory for names isn't that good and I don't wish to leave one out so let's just say they are all competent caring professionals who stay on top of everything and still manage to maintain healthy senses of humor. I like that a lot!

Leslie Shear11/20/2018

This was my first time at this dentist's office, and I was extremely satisfied. Doris was my hygienist, and she was very professional and personable. I enjoyed talking with her. She took her time with the cleaning, and did a really thorough job, making sure to let me (and Dr. Challenger) know about anything she noticed. Dr. Challenger was also nice, personable and professional. He has a great "chairside" manner! I had to get in for some follow up work after my appointment and they were very helpful getting me scheduled before the end of the year. A very well-run operation, from what I have seen so far!

Tyler Emerick1/10/2020

Bessy is hands down the best Dental hygienist in Madison!

Landon Jennings-Stoyles9/20/2018

I would highly recommend Madison Family Dental. Dental hygienist Tayler B., Dr. Wirtz, and the rest of the staff are very friendly, personable, honest and professional. I value that the staff actually gets to know me and feel that I can trust their service.