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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
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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)
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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

4.9 - 111 Google Reviews

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wayne ruhland4/20/2019

With a mouth full of high level dental challenges I can thank my dental team of Dr. Wirtz, Dr. Carmosino, Amber and Bessie that I can smile in the mirror each morning and still see most of my original teeth. It's taken the skill of an engineer, the knowledge of a physician, the eye of an artist and a heart full of kindness to achieve that for me. Five stars is not nearly enough for their efforts. My best salute is THANK YOU!Sincerely, Wayne

Katherine Paulsen10/20/2018

I have been seeing dental hygienist, Melissa M., for 5+ years. Melissa is AMAZING!!! I like her so much that I have followed her from Dr. Heim to Dr. Challenger. Both dentist are great.

Ted Ahn12/29/2019

I was here for my wisdom tooth removal several days ago. Dr. Mccombs, Mark, and Mary helped me out from the beginning to the end so well. I highly recommend this place.

Ellen Feigl10/02/2019

This was my first time at the Madison Family Dental Association and the whole experience was easy and relaxing. The service was friendly at all stages and left me feeling confident that I was getting the highest level of care for my teeth.

Maiyer Xiong9/25/2019

I always have the best experience when i go to my appts, when i first joined the dental i felt very welcome and everyone there was very helpful and they were always kind. Dr. Heim is fantastic she is always understanding and always open for any questions. She does a great job and always make sure you are okay when doing any procedures. Also her assistants are the best and so kind.