External Referrals - TMD and Orofacial Pain - 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

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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)

Previously Attempted Treatment(s) *

Pain Location

Please use your mouse to mark up the location where pain is reported.

Reset

Anticipated Management Needs

Nonsurgical

Surgical

Uncertain

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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
Pain Location
Previously Attempted Treatment(s)
Surgical Needs
Nonsurgical Needs
Uncertain Needs
Uploaded Supporting Files	No Files Uploaded