Information related to the Coronavirus (COVID-19) and U-M Dentistry

REFERRING

1. Referring Doctor Details

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PATIENT

2. Patient Details

Detailed procedure information will be specified on the next page.

PROCEDURES

3. Procedures

Select Procedures
Alveoplasty
Biopsy (Hard or Soft Tissue, Infection, Drainage, etc.)
Exposure
Exposure, Bond
Extractions (Including Bone Grafts, Socket Preservation, Wisdom Tooth Removal)
Frenectomy
Implant
Tori Removal

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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 Medical Insurance
Procedures
Extractions/Exposures
Implants
Surgical - Alveoplasty
Surgical - Frenectomy
Surgical - Tori Removal
Pathology/Biopsy
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