Referrals from dental practices and oral surgeons are crucial to our success and we thank you for your confidence in Prosthodontics of Madison.  Dr. Schaefer feels that communication regarding mutual patients is vital in delivering excellent and comprehensive patient care.  If you have any questions or concerns, please do not hesitate to call us directly at (608) 222-6606 or fax: (608) 222-2532.

Below you will find two ways to make referrals to our office:

          1. A Print & Fax/Mail Referral Form (pdf format) and
          2. An Online Referral Form from which you can send the referral by email directly
               from this page.


Print & Fax/Mail Referral Form

Print a paper Referral Form by clicking here and then, after completing it, either mail or fax it to the contact points shown below.  Note: This form is a PDF file and requires the Adobe Acrobat Plugin.  If necessary, please download Acrobat from Adobe's website.

Prosthodontics of Madison
Kendra S. Schaefer, DMD, LLC
4002 Monona Drive
Madison, WI  53716
  Tel: (608) 222-6606
Fax: (608) 222-2532

 

Online Referral Form

PATIENT AND REFERRER INFORMATION

Patient Name: (required)

Patient DOB:

Patient Home Phone:

Patient Work Phone:

Patient Cell Phone:

Referring Doctor: (required)

Referrer's Email: (required)

Referrer's Office Phone: (required)

Patient will call to schedule an appointment

An appointment has been scheduled for (date):

Please call patient to schedule an appointment

Please email patient to schedule an appointment

Patient's Email Address:

CHIEF REASON FOR REFERRAL           
(please use Comments field for additional information)

Extensive Restorative Considerations

Removable Prosthetics

Implant Prosthetics

Maxillofacial Prosthetics

Crown and/or Bridge Work

Facial Pain

Other Diagnosis

Additional Diagnostic Details

DIAGNOSTIC INFORMATION AVAILABLE           
(choose all that apply within last 12 months)

Diagnostic Casts

X-Rays

CT Scan

MRI

Diag Info Has Been or Will be emailed

Diag Info Has Been or Will be MAILED

Patient possesses diag info and will bring to the appointment

No Diagnostic Information is Available

 

Currently, you can not attach relevant photos and/or radiographs. If you have images, please email them to jen@prosthododnticsofmadison.com and make sure to reference the name of the patient in the subject or body of the message.

  

Please note: information sent using this form is
not secure and/or encrypted
according to HIPAA regulations.

 

 

 

 




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Prosthodontics of Madison • 4002 Monona Drive • Madison, WI 53716 • (608) 222-6606 • Fax:(608) 222-2532