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Orthodontic Referral Form


Thank you for your referral. We appreciate your willingness to allow us to work with you to meet your patient's orthodontic needs.

Currently our faculty practice clinic is a one-day-a-week orthodontic practice. We are one of the few orthodontic practices within the Twin Cities area that accepts insurance coverage through Minnesota Health Care programs. Due to high demand, there can be delays in how quickly we are able to schedule patients for new patient examinations. We will contact your patient as soon as possible.

Thank you for your understanding.

Referring Doctor

Refer To

Patient Information

Appointment Information


Patient will call to schedule appointment.
Please call patient to schedule appointment.

Patient will need an interpreter.

Patient has special needs.

Early/Limited Treatment
Full Orthodontic Treatment
Pre-Restorative Treatment
Surgical-Orthodontic Treatment
Other

Comments

Attachments

Maximum size for attachment: 15MB

Images

If you would like to include images for our staff to review please click the choose file button and select the image file. Then enter the date the image was taken. Finally click the blue 'Add' button. If your image was sucessfully added it will appear in the table below.



Image Name Date Taken
None added

Documents

If you would like include a document for our staff to review please click the choose file button and select the apporiate document. If you would like to upload multiple items, please follow the process to compress the items into one '.zip' file. Then click the choose file button and select the '.zip' file.


University of Minnesota Orthontic Faculty Practice
515 Delaware Street SE
Minneapolis, MN 55455
P: (612) 626-2011
W: www.gopherbraces.com