Oral Medicine Clinic

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DATE: 3-26-2023

UNIVERSITY OF MICHIGAN - EXTERNAL REFERRALS
ORAL AND MAXILLOFACIAL PATHOLOGY BIOPSY SERVICE
Phone: (800) 358-1011
Fax: 734-764-2469
Email: umoralpath@umich.edu

Patient Agreement to Pay for Services. In the event that my medical health insurance and/or Medicare/ Medicaid does not pay for laboratory, diagnostic, and any other fees, I understand and agree that I will be responsible for payment in full to the University of Michigan Oral Pathology Biopsy Service.

Patient Signature on File

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Print Patient Name

If patient is a minor, print Parent/Guardian Name

Signature (Patient, Parent/Guardian)

Date

PATIENT: General
Name
DOB
Own legal guardian?
Gender If Provided
Phone & Email
Address	,

PATIENT: Medical
Medical Conditions
History of Cancer
Medications
Insurance
Insurance Details

Current Lesion(s) & Description

DESCRIPTION

Clinical Diagnosis
Nature of Operation
Surgical Findings
Systemic or Topical Steroids?
Prior Biopsy / Other Lab?	Other Lab Info
Uploaded Files
Uploaded Files - Details	Radiograph(s): Clinical Photo(s): CBCT Report:

REFERRER
Name
Practice Name If Provided
NPI# If Provided
Phone & Email
Address	,

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)

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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

Is the patient their own legal guardian? *

Patient Medical Conditions
numbers, letters, hyphens, apostrophes

Patient Medications
numbers, letters, hyphens, apostrophes

Patient Dental Insurance *
please select one

Patient Medical Insurance
numbers, letters, hyphens, apostrophes

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)

3. Patient Information: Current Lesion(s):

If drawing multiple locations, please allow a brief pause between each (~1-2 seconds).
If choosing different colors for different lesions, you can close the color picker by clicking the word "Draw."

Please describe the lesion(s) *

What is your clinical/provisional diagnosis? *

What treatment has the patient had for this condition? *

Please elaborate on the outcome.

Did the patient have a previous biopsy? *

If so, please submit the report. If you do not have access to the report, please indicate the office where the biopsy was taken so that we can retrieve the report.

If our clinicians recommend a biopsy, please indicate your preference: *

I would like the patient to be referred back to our office for the biopsy procedure
I would like the biopsy procedure to be done at University of Michigan

External Referrals

Comprehensive Clinical Pathology Services

Please Review

Patient Signature on File

PATIENT: General

PATIENT: Medical

REFERRER

1. Doctor Information

2. Patient Information

3. Patient Information: Current Lesion(s):

Current Lesion(s)

Please describe the lesion(s) *

What is your clinical/provisional diagnosis? *

What treatment has the patient had for this condition? *

Please elaborate on the outcome.

Did the patient have a previous biopsy? *

If so, please submit the report. If you do not have access to the report, please indicate the office where the biopsy was taken so that we can retrieve the report.

If our clinicians recommend a biopsy, please indicate your preference: *

Is the patient currently using systemic or topical steroids? *

Other relevant information

How did you hear about our service? *

Image Uploads

Please let us know about your uploads *

Radiograph(s)?

Clinical Photograph(s)?

CBCT Report?