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Oral Surgery Referral Form

Currently, the Division of Oral Surgery has an extremely high number of referrals and limited providers. The average wait time for a consult is currently 6 months. If your patient needs emergency attention due to swelling and pain, please fill out the online referral and then email our referral coordinator at omsreferral@umn.edu to discuss options of the patient being seen sooner.
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 must call to schedule: Please wait 5-6 business days to call and schedule to ensure adequate time to process referrals.



Patient will need an interpreter.

Patient has special needs.

Patient interested in sedation*   Yes      No

Extractions
Implants
Lesion/Biopsy
Nerve
TMJ/Facial Pain
Obstructive Sleep Apnea
Cleft Lip & Palate
 Orthognathic Surgery **
    (Corrective jaw surgery)
* * Referral must come
   from an Orthodontist
Other


51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66

UR
A
B
C
D
E
F
G
H
I
J
UL

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

32
31
30
29
28
27
26
25
24
23
22
21
20
19
18
17

LR
T
S
R
Q
P
O
N
M
L
K
LL

82
81
80
79
78
77
76
75
74
73
72
71
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69
68
67

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.

Oral and Maxillofacial Surgery
515 Delaware Street SE, 7-174 Moos Tower
Minneapolis, MN 55455
P: (612) 625-2495
F: (612) 624-2669