Patient Referral Form

Thank you for referring a patient to us! Our team looks forward to providing them excellent care every step of the way.

Please fill out the below form and a member of our team will reach out to them soon to discuss next steps.

Patients Please Note: this form is for an outside provider to refer a patient to us. If you're a patient, please request an appointment.

Attention Appleton Endodontic Referrals: Due to an influx of endodontic patient needs, we are not able to accept outside endodontic referrals currently. If you are a provider referring a patient from Midwest Dental in the Fox Valley Area, we will gladly accommodate the patients who have CarePlus Dental Plans. We apologize for the inconvenience and hope to be able to service outside Endodontic referrals in the future.

>>> Appleton and Green Bay Oral Surgery and Periodontic Referrals <<<

Due to access constraints, we are currently not able to accept outside oral surgery or periodontic referrals. We apologize and hope this situation is resolved soon.