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TMD, Orofacial Pain and Dental Sleep Medicine Clinic Referral Form


Referring Doctor

Patient Information

Refer To

* Dental Sleep Medicine Providers

Appointment Information


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

Patient will need an interpreter.

Patient has special needs.

Jaw Pain or TMJ Pain
Ear Pain
TMJ Clicking
Jaw Locking
Headaches
Neuropathic/Nerve Pain
Non-odontogenic Tooth Pain
Sleep Apnea/Snoring
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.


TMD, Orofacial Pain, and Dental Sleep Medicine Clinic
515 Delaware Street SE, 6-440 Moos Tower
Minneapolis, MN 55455
P: (612) 626-0140
F: (612) 626-0138
E: tmdclinic@umn.edu
W: www.tmdclinic.umn.edu