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201 Sherman Avenue W, Fort Atkinson, WI 53538 || (920) 563-7323

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(920) 563-7323

Doctor Referral Information

Please use the form below to contact Dr. Stafford regarding a patient referral:

Patient Contact Information
Patient Name*
Patient Phone Number*
Patient Cell Phone Number
Email*
Referring Doctor*
Referral Information
Reason for Referral*
- Evaluation for TMJ Disorder
- Evaluation for Sleep Disorder
- Fabrication of sleep appliance due to snoring or CPAP intolerance
- Both
TMJ Symptoms*
- Headaches
- Migraines
- Jaw Pain
- Neck Pain
- Ear Pain
- Subjective hearing loss
- Ear Congestion or blockage
- Tinnitus (ringing in ears)
- Vertigo (Diziness)
- Clicking or popping in TMJ
- Sinus pain pressure
Sleep Symptoms*
- Snoring
- Constantly tired
- Morning headaches
- Diagnosed sleep apnea
- Reported gasping at night (possible sleep apnea)
- CPAP Intolerant
Patient Information
Has the patient had a sleep study?*
- Yes
- No
Did you already instruct the patient to call us?*
- Yes
- No
Other information or request:*
Comments
This field is for validation purposes and should be left unchanged.

201 Sherman Ave. W
Fort Atkinson WI 53538

Request Appointment

Monday

8:00AM - 12:00PM

Tuesday

9:00AM - 7:00PM

Wednesday

8:00AM - 5:00PM

Thursday

8:00AM - 12:00PM

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American Dental Association recognizes only nine specialty areas. Cosmetic dentistry, TMJ, Neuromuscular dentistry and Aesthetic dentistry are not part of these nine specialty areas. While Dr. Stafford is a general dentist that has received many years of training in these areas, since there is no ADA recognition of specialty in these areas, Wisconsin rules require the following statement. "Cosmetic dentistry, TMJ, Neuromuscular dentistry and Aesthetic dentistry are specialty areas not recognized by the ADA that requires no specific educational training to advertise this service".

Home
About
Services
Research
Patient Testimonials
Contact
- Request Appointment
- Doctor Referral Information

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