Section of Oral & Maxillofacial Surgery

Oral Surgery Patient 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 734-936-4761.

* indicates required fields

Patient Information
* Last Name:      * First Name:

* Date of Birth:       Sex:

U-M Registration Number (if known):

Street Address:       City:

State:       Zip Code:

* Home Phone Number:

* Cell Phone Number:

E-mail Address:

Medical Insurance:

Dental Insurance:

* Reason for Referral:

Refer To:


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Referring Physician Information
* Last Name:      * First Name:

Street Address:       City:

State:       Zip Code:

* Office Phone Number:

* E-mail Address:       Best Form of Contact:

Specialty:

   Primary Care
   Oral Surgery
   Orthodontics
   Dentistry
   Other    
Primary Care Physician
Last Name:      First Name:

Street Address:       City:

State:       Zip Code:

Office Phone number:

E-mail address:

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.

While type of insurance does not effect quality of care, your patient is responsible to know if he/she may be treated at our facility and if an insurance referral is needed from a primary care physician. If these guidelines are not followed, your patient may receive a bill for services rendered. The patient is able to contact member services located on his/her insurance card for more information. Payment for each visit is expected at the time of service for patients with no insurance, insurance coverage that does not pay for the type of treatment we render, and insurance policies we do not accept.

We do not accept the following insurance: BCN Adv, HAP assigned to Henry Ford, DMC, Genesys, or county insurance other than Washtenaw.