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Advanced Prosthodontics Department Referral Form

Currently, the Division of Advanced Prosthodontics has an extremely high number of referrals and limited providers. The average wait time for a consult is currently 6 months. This form must be filled out by a dentist to ensure proper completion and processing. Misuse of referral forms may lead to delay in patient care or referral rejection.

Form should be filled out by the referring doctor to ensure accuracy of information and fastest processing.

Referring Doctor

Doctor's First Name* Doctor's Last Name* Doctor's Email* Doctor's Clinic Name* Clinic's Mailing Address*

Clinic's Phone Number*

Refer To*

Patient Information

Patient's First Name* Patient's Last Name* Patient's Date of Birth* Patient's Sex* Patient's Mailing Address*

Patient's Phone Number*
Patient's Email

Patient Insurance

Provide dental insurance information so we can appropriately coordinate benefits and/or provide prior authorization as needed.

Dental*

Appointment Information

Comments

All imaging is required for review. Upload imaging in attachments below.

If there is no imaging, please state in the comments below.

Attachments

Maximum size for attachment: 15MB

Images

Upload x-rays, patient photos, and patient insurance card(s) for our staff to review. Please click the choose file button and select the image file. Then enter the date the image/photo/insurance card was captured. Finally click the blue 'Add' button. If your file was successfully 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.

Advanced Prosthodontics Department
515 Delaware Street SE, 9-176 Moos Tower
Minneapolis, MN 55455
P: (612) 624-6644
F: (612) 626-2655

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