Referrals

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

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)

3. Guardianship

Does the patient consent for themselves? *

Guardian Name

Required if there is a guardian

Guardian Address

Guardian Phone

Required if there is a guardian

Guardian Email

4. Patient Medical History & dental information

Relevant Medical History *

Please list all of patient’s active medical diagnoses and/or current medical problem list. A comprehensive list helps staff determine the most appropriate clinic setting for treatment.

Is the patient being referred for evaluation before a medical procedure? *

Examples may include clearance for initiating hemodialysis, organ transplant, or chemotherapy.

Please provide details

Does the patient require any of the following for treatment? *

Administration of blood products or transfusion during treatment
Continuous cardiac monitoring
General anesthesia for dental care

Please provide details

ToolTips:

1. Administration of blood products or transfusion during treatment: administration of blood products such as red blood cells or platelets for treatment.
2. Continuous heart monitoring: real-time tracking of heart activity during care to detect irregularities.
3. General anesthesia: a medication-induced sleep state used during procedures to block pain and awareness.

Is the patient confined to a bed/gurney? *

Please provide details

Is there any additional information that you think we should know about this patient?

Image Uploads

Accepted File Types: jpg, jpeg, png, gif, pdf, docx, dcm
Only .jpeg files are accepted for images/radiographs
For all uploads, please choose a relevant date for each radiograph or document
(Upload examples: Clinical/chart notes, guardianship papers, face sheets, and/or radiographs)

Add File or Image

External Referrals

Hospital-Based and Integrated Special Care Dentistry

Read This First

1. Doctor Information

2. Patient Information

3. Guardianship

Does the patient consent for themselves? *

Guardian Name

Guardian Address

Guardian Phone

Guardian Email

4. Patient Medical History & dental information

Relevant Medical History *

Is the patient being referred for evaluation before a medical procedure? *

Please provide details

Does the patient require any of the following for treatment? *

Please provide details

Is the patient confined to a bed/gurney? *

Please provide details

Is there any additional information that you think we should know about this patient?

Image Uploads

Before Proceeding

The patient being referred must be seen in the Pediatric clinic

Given the patient's treatment needs, a referral needs to be submitted to a different specialty clinic listed

Hospital-Based and Integrated Special Care Dentistry

Read This First

1. Doctor Information

2. Patient Information

3. Guardianship

Does the patient consent for themselves? *

Guardian Name

Guardian Address

Guardian Phone

Guardian Email

4. Patient Medical History & dental information

Relevant Medical History *

Is the patient being referred for evaluation before a medical procedure? *

Please provide details

Does the patient require any of the following for treatment? *

Please provide details

Is the patient confined to a bed/gurney? *

Please provide details

Is there any additional information that you think we should know about this patient?

Image Uploads