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220 W Broadway, Madison, WI 53716 Phone: 608-222-6160 Fax: 608-222-6248
Complete the Online Form

Please read carefully before submitting!
- Referral patients needing dental treatment MUST be under age 6 if they have BadgerCare only
- We do accept new pediatric dental patients through age 11 with a primary insurance
- We are currently not accepting new routine dental care patients with BadgerCare only
- We do accept new orthodontic patients of any age (No BadgerCare accepted)
Practice Name
Practice Address

Street Address

Street Address Line 2

CityState

Zip Code
Practice Phone

Area CodePhone Number
Referring Doctor's Name
Doctor you are referring to
Patient you are referring
Patient Name

First NameLast Name
Patient DOB

MonthDayYear
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone Number OR Patients Over 18yrs Old

Area CodePhone Number
Parent/Guardian's Preferred Language
Reason for Referral
Would you like a completed tx letter?
Where would you like it sent to?
example@example.com
Relevant History
X-Rays (choose at least one)
Bitewings Date

MonthDayYear
Date
PA Date

MonthDayYear
Date
Pan Date

MonthDayYear
Date
Ceph Date

MonthDayYear
Date
Upload Digital X-Rays (Please do not send x-rays as PDF documents!)

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Relevant History
Date of Last Prophy

MonthDayYear
Please List All Known Medical Conditions
Please Provide All Relevant Information On Previous attempts to provide treatment
Insurance Info
Please include Insurance Company / Subscriber's Name / Subscribers DOB / Subscriber # or Member ID #
Upload any other documents you may need here

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