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Michigan Medicine Clinic & Pediatric Oral & Maxillofacial Surgery at Mott Children’s Hospital

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  1. For patients requiring wisdom teeth extraction, other extraction, implants, or treatment for exposure who do not have an underlying severe medical condition such as congenital heart disease, a bleeding disorder, or other severe underlying medical condition, please submit your referral to the School of Dentistry's Oral & Maxillofacial Surgery clinic.

  2. For patients requiring treatment for TMJ disorder, if the care needed is non-surgical, please submit your referral to the TMD Orofacial Pain Clinic.

1. Doctor Information

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2. Patient Information

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3. Details

Patient Age Category *
Patient Severe Condition *

Does the patient have congenital heart disease, a bleeding condition, or any other severe underlying medical condition? (If Yes, please add any details to the 'Reason for Referral' field)

Patient Conditions (check all that apply)

* For patients needing extractions, implants, or exposure treatment who do not have any severe underlying medical conditions (congenital heart disease, a bleeding condition, etc.) - and - who do not have any of the non-asterisked conditions selected above, please submit your referral to the School of Dentistry's Oral & Maxillofacial Surgery clinic.

** For patients with TMJ disorder who do not have any severe underlying medical conditions (congenital heart disease, a bleeding disorder, etc.) - and - who do not have any of the other, non-asterisked conditions from the list above, please submit your referral to the Temperomandibular Disorders/Orofacial Pain Clinic.

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