Referrals

Only scans with interpretation are available through this form at this time.

1. Doctor Information

Doctor First Name *
letters, spaces, hyphens, apostrophes

Doctor Last Name *
letters, spaces, hyphens, apostrophes

Name of Practice/Business
letters, spaces, hyphens, apostrophes

Doctor NPI #
numbers only, 10 digits required, or 15 if using prefix 80840

Doctor Phone *
numbers, hyphens
(123-123-1234)

Doctor Email *
numbers, letters, hyphens, apostrophes
(name@example.com)

Doctor Street *
numbers, letters, spaces, hyphens, apostrophes

Doctor City *
numbers, letters, spaces, hyphens, apostrophes

Doctor State *
Only U.S. States are currently available

Doctor Zip Code *
numbers, hyphen
(format: 12345 or 12345-6789)

Click the blue button to save currently entered referring doctor information, so that it loads automatically next time.
To overwrite previously saved information, enter new information and click save again.

2. Patient Information

Patient First Name *
letters, spaces, hyphens, apostrophes

Patient Last Name *
letters, spaces, hyphens, apostrophes

Patient Date of Birth *
numbers, hyphens (ex: 01-25-1997)

Patient Gender
optional

Is the patient their own legal guardian? *

Patient Medical Conditions
numbers, letters, hyphens, apostrophes

Patient Medications
numbers, letters, hyphens, apostrophes

Patient Dental Insurance *
please select one

Patient Medical Insurance
numbers, letters, hyphens, apostrophes

Patient Street *
numbers, letters, spaces, hyphens, apostrophes

Patient City *
numbers, letters, spaces, hyphens, apostrophes

Patient State *
Only U.S. States are currently available

Patient Zip Code *
numbers, hyphen
(format: 12345 or 12345-6789)

Patient Phone *
numbers, hyphens
(123-123-1234)

Patient Email
numbers, letters, hyphens, apostrophes
(name@example.com)

Region and Field of View

Full Head
Both Jaws
TMJ - Closed Mouth
TMJ - Open Mouth

Full Maxilla
Right Maxilla
Anterior Maxilla
Left Maxilla

Full Mandible
Right Mandible
Anterior Mandible
Left Mandible

Comments on Region and Field of View

Appointments are made through Dental Faculty Associates Perio (DFA Perio) (734-764-2700).
Patient should report to DFA (room 3370, third floor, School of Dentistry) 30 minutes before appointment to register.
Registration material will be sent to the patient in advance if there is enough time before the appointment.

Erika Benavides, DDS, PhD
Diplomate, American Board of Oral and Maxillofacial Radiology
Fabiana Soki, DDS, MDSc, PhD
University of Michigan School of Dentistry Dental Faculty Associates
1011 N. University Avenue, Room 3370, Ann Arbor, MI 48109-1078
Tel: 734-764-2700

External Referrals

Cone Beam CT Referral

1. Doctor Information

2. Patient Information

3. Details *

Reasons for Scan

Region and Field of View

Scan Options

Image Data Output

Other Referral Comments