Dental Specialty Care Done Right

Online Referrals

The green way.
No writing, scanning, saving or sending.

WisNova Innovative Dental Specialists
Email:  referral@wisnova.com
Phone:  262.632.5455

"*" indicates required fields

Patient Information

Name*
MM slash DD slash YYYY
Please provide a working email if available so that we can send your patient a welcome email with directions to our office, registration instructions and next steps.

Referring Doctor Information

You will receive an email confirmation of this referral for your records.
Endodontics
Periodontics
Anesthesia
Patients interested in or required to have Oral or I.V. Sedation are seen for a consultation prior to procedure.
Drop files here or
Max. file size: 16 MB.

    Please Note - A Recent Full Mouth Series Is Required If Requesting a Full Periodontal Evaluation.

    Teeth To Be Evaluated
    This field is for validation purposes and should be left unchanged.