Learn About

Online Referral

Comfort-Driven Periodontics & Lasting Results.

A confirmation will be immediately emailed to the address you provide. Save this for your files and/or to print a copy for the patient. When completing the form, you may elect to have the patient receive a digital copy as well.
First time? Try it out and use "TEST" as the patient name!

*All fields are required for a successful submission.

First & Last Name

Patient's DOB

Phone Number

Email Address

Additional Comments Regarding Radiographs

Remarks or Restorative Treatment Plans

Same Day Treatment

If possible, the patient would prefer exam & treatment to be scheduled the same day (one visit).

Yes No

DDS Last Name

DDS First Name

By providing my wireless phone number and/or email, I agree and give consent to receive communication from IndyPerio, via text message and/or email.

Simple Steps To

Get Started

Ready to take the first step toward healthier gums and a stronger smile? Get started by choosing a location and scheduling your consultation with our expert team today.

Select a Location

Choose the IndyPerio office that’s most convenient for you—Indianapolis, Kokomo, or Richmond.

Schedule Your Appointment

Request your visit online or by phone at a time that works best for your schedule.

Fill Out Patient Forms

Complete your new patient forms ahead of time to help make your visit smooth and efficient.

Meet With Dr. Wiland

Visit our office to receive a personalized evaluation and expert care focused on your periodontal and implant health.