Referrals

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

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

Doctor First Name *

Doctor Last Name *

Name of Practice/Business

Doctor NPI #

Doctor Phone *

Doctor Email

Doctor Street

Doctor City *

Doctor State *

Doctor Zip Code

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Patient First Name *

Patient Last Name *

Patient Date of Birth *

Patient Gender

Is the patient their own legal guardian? *

Patient Dental Insurance

Patient Medical Insurance

Patient Street *

Patient City *

Patient State *

Patient Zip Code

Patient Phone *

Patient Email

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

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1. Doctor Information

2. Patient Information

3. Details

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