External Referrals
Referrals List
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Michigan Medicine Clinic & Pediatric Oral & Maxillofacial Surgery at Mott Children’s Hospital
1. Doctor Information
Doctor First Name *
(required)
Doctor Last Name *
(required)
Name of Practice/Business
Doctor NPI #
Doctor Phone *
(required)
Doctor Email
Doctor Street
Doctor City *
(required)
Doctor State *
(required)
Select a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Washington DC
Deleware
Florida
Georgia
Hawaii
Idaho
Illinios
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Doctor Zip Code
Save Information Above
For future submissions
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 *
(required)
Patient Last Name *
(required)
Patient Date of Birth *
(required)
Patient Gender
Choose one
Male
Female
Intersex
Non-binary
Is the patient their own legal guardian? *
(required)
Yes
No
Patient Dental Insurance
(required)
-Select One-
None
Healthy Kids
Healthy MI
Healthy MI - United Health Care
Healthy MI - DentaQuest
Healthy MI - Molina
Healthy MI - BC/BS
Straight Medicaid
Private/Commercial Insurance
Other
Patient Medical Insurance
Patient Street *
(required)
Patient City *
(required)
Patient State *
(required)
Select a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Washington DC
Deleware
Florida
Georgia
Hawaii
Idaho
Illinios
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Patient Zip Code
(required)
Patient Phone *
(required)
Patient Email
3. Details
Reason for Referral *
Patient Age Category
Adult (25 and over)
Pediatric (24 and under)
Select a Provider
No Preference
Sharon Aronovich DMD
Karen Carver MD, DDS
Amy Chin MD, DDS
Sean Peter Edwards MD, DDS
Paulo Zupelari Goncalves DDS
Mohamed A Hakim DDS
Hsiao Hsung DDS
Justine Sherylyn Moe MD, DDS
Paul Shivers MD, DDS
Brent Benson Ward MD, DDS, FACS, FACD
Preferred Time
Within a week
Within a month
No preference
4. Images/Documents
(required)
Most image and radiograph filetypes are accepted
Add File or Image
Select a File
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