External Referrals - Hospital Dentistry - University of Michigan School of Dentistry

REFERRING

1. Referring Doctor Details

Referring Doctor First Name *

Referring Doctor Last Name *

Referring Doctor NPI Number *

Referring Doctor Phone *

Referring Doctor Email

We do not share your email.

Referring Doctor Street Address *

Referring Doctor City *

Referring Doctor State *

Referring Doctor Zip/Postal Code *

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PATIENT

2. Patient Details

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Patient Gender

Is patient their own
legal guardian? *

Yes

Patient Street Address *

Patient City *

Patient Zip/Postal *

Patient Phone *

Patient Phone Type

Cell Home Unknown

Patient Email

Reason(s) for Referral *

Detailed procedure information will be specified on the next page.

Patient Medical Conditions and Allergies

Patient Medications

Patient Dental Insurance *

If Private/Commercial or Other, Please Specify

Patient Medical Insurance

ADDITIONAL INFORMATION

3. Additional Information

Treatment

Diagnosis Code (If Known)

Chief Concern *

Symptoms *

Medical History *

(That contributes to referral)

Dental History *

(What has been attempted and worked/not worked in the past?)

Explain any limitations/barriers to care in a routine setting *

Head and Neck/Oral Exam Findings *

Type of Care Referred

Comprehensive Care

Problem-Focused Care

Explain Type of Care

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REVIEW

4. Review and Submit

Referring Doctor Details
Referring Doctor
NPI
Street Address
City, State Zip	,
Phone
Email

Patient Details
Patient
DOB, Gender, Guardian	, ,
Street Address
City, State Zip	,
Phone
Email
Reason for Referral
Patient Medical Conditions
Patient Medications
Patient Dental Insurance
Patient Dental Insurance Detail
Patient Medical Insurance

Additional Information
Diagnosis Code (If Known)
Chief Concern
Symptoms
Medical History
Dental History
Limitations/Barriers to Care
Head and Neck/Oral Exam Findings
Type of Care Referred
Referred Care Explanation
Uploaded Supporting Files	No Files Uploaded