Referrals

1. Doctor Information

Doctor First Name *
letters, spaces, hyphens, apostrophes

Doctor Last Name *
letters, spaces, hyphens, apostrophes

Name of Practice/Business
letters, spaces, hyphens, apostrophes

Doctor NPI #
numbers only, 10 digits required, or 15 if using prefix 80840

Doctor Phone *
numbers, hyphens
(123-123-1234)

Doctor Email *
numbers, letters, hyphens, apostrophes
(name@example.com)

Doctor Street *
numbers, letters, spaces, hyphens, apostrophes

Doctor City *
numbers, letters, spaces, hyphens, apostrophes

Doctor State *
Only U.S. States are currently available

Doctor Zip Code *
numbers, hyphen
(format: 12345 or 12345-6789)

Click the blue button to save currently entered referring doctor information, so that it loads automatically next time.
To overwrite previously saved information, enter new information and click save again.

2. Patient Information

Patient First Name *
letters, spaces, hyphens, apostrophes

Patient Last Name *
letters, spaces, hyphens, apostrophes

Patient Date of Birth *
numbers, hyphens (ex: 01-25-1997)

Patient Gender
optional

Patient Medical Conditions *
numbers, letters, hyphens, apostrophes

Patient Medications
numbers, letters, hyphens, apostrophes

Patient Medical Insurance *
numbers, letters, hyphens, apostrophes

Is The Patient Their Own Legal Guardian? *

Patient Street *
numbers, letters, spaces, hyphens, apostrophes

Patient City *
numbers, letters, spaces, hyphens, apostrophes

Patient State *
Only U.S. States are currently available

Patient Zip Code *
numbers, hyphen
(format: 12345 or 12345-6789)

Patient Phone *
numbers, hyphens
(123-123-1234)

Patient Email
numbers, letters, hyphens, apostrophes
(name@example.com)

Image Uploads (optional)
Most image and radiograph filetypes are accepted

Please upload a recent sleep study and prescription for oral appliance therapy. A sleep study and prescription are required to submit the referral to the School of Dentistry. Please call 734-763-3326 with any questions.
Please upload a global referral. A referral is required to submit the referral to the School of Dentistry. Please call 734-763-3326 with any questions.

Important: Be sure to select a date to the right of each uploaded file to indicate when the file was generated/completed.

Add a File

External Referrals

Obstructive Sleep Apnea Clinic

1. Doctor Information

2. Patient Information