Section of Oral & Maxillofacial Surgery

Hospital Dentistry Referral Form

Thank you for your interest in referring a patient to University of Michigan, either the Hospital Dentistry Clinic or the School of Dentistry. Please complete the information below so we can triage and most expeditiously provide care for your patient.

Questions? Contact us at 734-763-8006.

* indicates required fields

Patient Information
* Last Name:      * First Name:

* Date of Birth:

U-M Registration Number (if known):

Contact Person:       Relationship:

Street Address:       City:

State:       Zip Code:

* Home Phone number:

* Cell Phone number:

E-mail address:

* Reason for Referral:

Current Signs / Symptoms:

Is the patient medically compromised or neurologically impaired?
If yes, please describe
.

Based on assessment, can the patient be treated in a routine dental setting?
If no, please explain
.

If the patient is a Wayne/Oakland/Macomb resident, has a referral been made to the University of Detroit/University. Hospital?

Result:

Medical History:

Medication

List all medications and supplements (vitamins and herbs) you currently take:

Medication
Daily Dose
Medication
Daily Dose
Medication
Daily Dose
Medication
Daily Dose
Medication
Daily Dose
Medication
Daily Dose
Medication
Daily Dose
Medication
Daily Dose
Allergies Allergies to Medications:

Medication
Reaction
Severity
Medication
Reaction
Severity
Medication
Reaction
Severity
Medication
Reaction
Severity
Medication
Reaction
Severity
Medication
Reaction
Severity
Enter name of Allergen, Type of Reaction and if Reaction is Mild or Severe

Allergies to Environmental Particles:

Allergen
Reaction
Severity
Allergen
Reaction
Severity
Allergen
Reaction
Severity
Allergen
Reaction
Severity
Allergen
Reaction
Severity
Allergen
Reaction
Severity
Enter name of Allergen, Type of Reaction and if Reaction is Mild or Severe

Allergy to Latex?:

If Yes (Enter type of reaction and mild/severe reaction)

Reaction: Severity:
Referring Physician Information * Last Name:      * First Name:

Street Address:       City:

State:       Zip Code:

* Office Phone number:       Best Form of Contact:

* E-mail address:

If Referred by a Dentist:

Oral Examination Reveals:

The Following Treatment has been Provided:

Radiograph

**If you have radiographs and would like to submit them digitally:

  • Please use MiShare
  • Use OralSurg-HospDent@med.umich.edu as the "Recipient Email"
  • Please do not email Patient Medical Information

Otherwise please have the patient bring them at the time of their appointment.