THIS SITE IS CURRENTLY UNDERGOING MAINTENANCE
During this time, the referral forms may not funciton as expected.
Estimated Completion: 3:00pm EST

Temporomandibular Disorders/Orofacial Pain Clinic

Our clinic is not accepting new patient referrals on a temporary basis.
We are committed to providing the highest quality care to our existing patients and will resume accepting new patients June 2025.
Thank you for your understanding and patience.

1. Doctor Information

(required)
letters, spaces, hyphens, apostrophes
(required)
letters, spaces, hyphens, apostrophes
(required)
letters, spaces, hyphens, apostrophes

numbers only, 10 digits required, or 15 if using prefix 80840
(required)
numbers, hyphens
(123-123-1234)
(required)
numbers, letters, hyphens, apostrophes
(name@example.com)
(required)
numbers, letters, spaces, hyphens, apostrophes
(required)
numbers, letters, spaces, hyphens, apostrophes
(required)
Only U.S. States are currently available
(required)
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

(required)
letters, spaces, hyphens, apostrophes
(required)
letters, spaces, hyphens, apostrophes
(required)
numbers, hyphens (ex: 01-25-1997)

optional
(required)

numbers, letters, hyphens, apostrophes

numbers, letters, hyphens, apostrophes
(required)
please select one

numbers, letters, hyphens, apostrophes
(required)
numbers, letters, spaces, hyphens, apostrophes
(required)
numbers, letters, spaces, hyphens, apostrophes
(required)
Only U.S. States are currently available
(required)
numbers, hyphen
(format: 12345 or 12345-6789)
(required)
numbers, hyphens
(123-123-1234)

numbers, letters, hyphens, apostrophes
(name@example.com)

3. Procedures and Imaging *

Treatment

Reason for Referral
Previous Attempted Treatments *
Pain Location

Draw


Pain Location

Anticipated Management Needs

Nonsurgical
Surgical
Uncertain

Image Uploads

(required) Accepted File Types: jpg, jpeg, png, gif, pdf, docx, dcm
For each file you add, be sure to select the date it was taken.
Add File or Image