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Oral Surgery Referral Form


Form should be filled out by the referring doctor to ensure accuracy in recommendation for any surgical treatment.

Referring Doctor

Refer To*

Patient Information

Patient Insurance

Provide ALL insurance for both medical and dental so we can appropriately coordinate benefits and/or provide prior authorization as needed.

Appointment Information


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

Patient will need an interpreter.

Patient has special needs.

Implants
Orthognathic Surgery
TMJ/Facial Pain
Obstructive Sleep Apnea
Nerve
Lesion/Biopsy
Cleft Lip & Palate
Extractions
Other


UR

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Comments

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.


University of Minnesota Dental Clinics
515 Delaware Street SE, 16-205 Moos Tower
Minneapolis, MN 55416
P: (612) 625-2495
F: (612) 624-2669