External Referrals
Referrals List
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THIS SITE IS CURRENTLY UNDERGOING MAINTENANCE
During this time, the referral forms may not funciton as expected.
Estimated Completion: 3:00pm EST
Temporomandibular Disorders/Orofacial Pain Clinic
1. Doctor Information
Doctor First Name *
(required)
letters, spaces, hyphens, apostrophes
Doctor Last Name *
(required)
letters, spaces, hyphens, apostrophes
Name of Practice/Business
(required)
letters, spaces, hyphens, apostrophes
Doctor NPI #
numbers only, 10 digits required, or 15 if using prefix 80840
Doctor Phone *
(required)
numbers, hyphens
(123-123-1234)
Doctor Email *
(required)
numbers, letters, hyphens, apostrophes
(name@example.com)
Doctor Street *
(required)
numbers, letters, spaces, hyphens, apostrophes
Doctor City *
(required)
numbers, letters, spaces, hyphens, apostrophes
Doctor State *
(required)
Only U.S. States are currently available
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 *
(required)
numbers, hyphen
(format: 12345 or 12345-6789)
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)
letters, spaces, hyphens, apostrophes
Patient Last Name *
(required)
letters, spaces, hyphens, apostrophes
Patient Date of Birth *
(required)
numbers, hyphens (ex: 01-25-1997)
Patient Gender
optional
Choose one
Male
Female
Intersex
Non-binary
Is the patient their own legal guardian? *
(required)
Yes
No
Patient Medical Conditions
numbers, letters, hyphens, apostrophes
Patient Medications
numbers, letters, hyphens, apostrophes
Patient Dental Insurance *
(required)
please select one
-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
numbers, letters, hyphens, apostrophes
Patient Street *
(required)
numbers, letters, spaces, hyphens, apostrophes
Patient City *
(required)
numbers, letters, spaces, hyphens, apostrophes
Patient State *
(required)
Only U.S. States are currently available
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)
numbers, hyphen
(format: 12345 or 12345-6789)
Patient Phone *
(required)
numbers, hyphens
(123-123-1234)
Patient Email
numbers, letters, hyphens, apostrophes
(name@example.com)
3. Procedures and Imaging *
Treatment
Reason for Referral
Previous Attempted Treatments *
Pain Location
Draw
Color
Line Width
Clear
Download Canvas
Pain Location
Anticipated Management Needs
Nonsurgical
Nonsurgical
Surgical
Surgical
Uncertain
Uncertain
Image Uploads
(required)
Accepted File Types: jpg, jpeg, png, gif, pdf, docx, dcm
For each file you add, be sure to select the date it was taken.
Add File or Image
Select a File
Browse
Remove
