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When you appear for your first appointment, it is always
best to bring in the following items:
1. A Referral Form from your dentist is appreciated, but not required. There
is a Referral Form link below which allows you or your dentist to obtain a Referral Form immediately. If your dentist does
not have referral forms from my office, please let me know and forms can be mailed to them.
2. Any Xrays taken within the past two years - Preferrably Full Mouth Xrays or a Pan - Your general dentist
can also E-mail the Xrays (if digital) to tck@kelleyperio.com. You can have your general dentist mail them to : Thomas C. Kelley,D.D.S.,M.S.D.,L.L.C.,
17280 W. North Ave., STE 203, Brookfield, Wisconsin 53045.
3. Dental and Medical
Insurance Cards
4. If you require premedication, please take it as prescribed prior to your appointment.
5. Lastly you may download, print, and complete our new patient forms before your appointment in order to save time--
just click the links below for the following forms: Patient Registration / Dental
& Medical History / HIPAA. Or these forms may be completed in our office when you come for your appointment.
To help you save you time and money, check with your insurance in advance to see if the periodontist you have been referred
to is listed as a provider for your plan. You may end up paying exorbitant fees if you go to a provider who is not part of
your insurance plan- be warned. Second opinions are available. Discounted or free services are not offered for second opinions.
If you don't have insurance, I can offer you a competitive out of pocket price.
Referral Form For Your Dentist- You can have your general dentist fill out one of my referral forms by printing it out for
them on the link below or they can download my form at their office. Note that a referral is not necessary to see me.
Referral Form
Patient Registration / Dental & Medical History
Notice of Privacy Practices: Please read and note that we will only use your confidential information for communication with
your dentist/specialist and insurance.
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