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Schedule an Appointment

Appointment Request Form

The first step to getting the spectacular smile you have always wanted is to schedule an appointment. To schedule your complimentary consultation, please complete and submit the request form below. We will contact you shortly to confirm your appointment.

    * - Required Fields

    Contact Information:

    Your Name – First and Last*

    Address Line 1*

    Address Line 2



    Zip Code*

    Phone Number*

    Email Address*

    Are you a new Patient?*

    If you referred to our practice, please specify below:
    Patient's Name or Referring Dentist

    Is there anyone who would also like to be seen:

    Dental Insurance Information:

    Madison Pediatric Dentistry is a premier in-network provider for ALL PPO insurances. Please enter your dental insurance information below so we can verify your child/children dental benefits.

    Insurance Carrier/Company:

    Policy Number/Subscriber ID:

    Group Number:

    Insurance Carrier Phone number:

    Prospective Patient (Child 1) Name:

    Prospective Patient (Child 1) Date of Birth:

    Prospective Patient (Child 2) Name:

    Prospective Patient (Child 2) Date of Birth:

    Prospective Patient (Child 3) Name:

    Prospective Patient (Child 3) Date of Birth:

    Policy Holder full name:

    Policy Holder Date of Birth:

    Which time(s) of the day are you available?*
    No PreferenceMorningAfternoon

    Please describe the nature of your appointment: