Oral and Maxillofacial Surgery Referral Form University of Illinois at Chicago College of Dentistry Oral Surgery Fax 312 -996-5987 email oralsurgery uic.edu If emergency please call Dental Urgent Care at 312 -996-8636 Date of referral Referred by Office phone/email/fax Patient name/parent for minors Patient phone Patient email Patient INSURANCE information Dentoalveolar surgery Extraction teeth s Please mark teeth to be extracted on diagram Alveoplasty Incision and drainage Apicoectomy Biopsy Expose and bond Frenectomy Dental implants Pathology/Biopsy Orthognathic evaluation TMJ evaluation Cosmetic facial surgery Radiographs Attached to this referral Will send by email oralsurgery uic.edu None available Medical History Negative Significant Special needs Anesthesia Recommendations Local anesthesia IV sedation General anesthesia operating room Indicate facial injury swelling or other findings Other/Comments Person completing this form Signature initials Phone Fax email Note UIC Missed Ap....
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How to fill out the Uic Referral Form online
The Uic Referral Form is a key document for referring patients to the University of Illinois at Chicago College of Dentistry for oral and maxillofacial surgery. This guide offers clear, step-by-step instructions to assist users in completing the form online easily and effectively.
Follow the steps to successfully complete the Uic Referral Form
- Click ‘Get Form’ button to obtain the form and open it in a digital editor.
- Enter the date of referral in the designated field at the top of the form.
- Provide your name as the referring practitioner, along with your office phone number, email, and fax information.
- Fill in the patient’s name or parent’s name if the patient is a minor, and provide their contact information, including phone and email.
- Detail the patient's insurance information in the relevant section.
- Indicate the required dentoalveolar surgery, marking the relevant checkboxes and providing specific tooth numbers when necessary.
- If needed, specify any additional procedures such as alveoplasty, incision and drainage, or biopsy, amongst others.
- Include any dental implant numbers or pathology details in the provided fields.
- For orthognathic evaluation and TMJ evaluation, briefly describe the requirements.
- Identify whether radiographs are attached, to be sent by email or mail, or indicate if none are available.
- Provide information regarding the patient's medical history, noting if it is negative or detailing any significant issues or special needs.
- Choose anesthesia recommendations appropriate for the procedure.
- Complete any other comments or additional instructions in the provided space.
- Finally, enter your name, signature or initials, phone, fax, and email as the person completing the form.
- Review the entire form for accuracy and completeness, then proceed to save changes, download, print, or share the form as necessary.
Complete the Uic Referral Form online and ensure you provide all necessary details for a smooth referral process.
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How to become a patient at UIC dental school?
Becoming a patient at UIC Dental School involves a few straightforward steps. First, you will need to obtain a referral from your dentist or healthcare provider and complete the necessary UIC Referral Form. Once the form is submitted and reviewed, the school will contact you to discuss available services and schedule your appointment. Embracing this process allows you to access quality dental care at UIC.
How do I fill out a referral form?
To fill out the UIC Referral Form, start by providing the patient's personal details, including contact information and insurance coverage. Next, include a brief medical history relevant to the dental care requested. Ensure that core areas are addressed, such as the reason for referral and any specific treatments needed. If challenges arise during completion, reach out to the UIC Dental School for assistance.
How to fill out the referral form?
Filling out the UIC Referral Form requires accurate information about the patient's dental history and current needs. The form typically asks for details about previous treatments, ongoing concerns, and the referring source's information. You should take your time to ensure all sections are completed correctly. If you need help, ask the healthcare provider completing the form to guide you through each step.
What is a referral example?
A referral example would be when a general dentist recommends you to a specialist for advanced treatment. For instance, if you need orthodontic care, your dentist might issue a referral to the UIC Dental School. This documentation typically includes your dental history and specific reasons for the referral. Relevant details help the specialists at UIC provide you with the best possible care after reviewing your UIC Referral Form.
Who fills out the referral form?
Typically, the referring dentist or healthcare provider fills out the UIC Referral Form on behalf of the patient. This ensures that all necessary medical history and reasons for referral are included. However, if you are a patient seeking assistance, you can also inquire at the UIC Dental School about how to initiate this process. Completing the UIC Referral Form is often the first step in receiving comprehensive dental care.
Does UIC dental school accept Medicaid?
Yes, UIC Dental School accepts Medicaid for eligible patients. If you qualify for Medicaid, you can access various dental services offered by the school. It's advisable to verify your coverage directly with Medicaid representatives prior to your appointment. Consider filling out the UIC Referral Form to start your journey toward receiving care.
What are the 3 types of dental implants?
There are three common types of dental implants that you can choose from Endosteal, subperiosteal, and zygomatic. Endosteal is the safest and most common, followed by subperiosteal, and then zygomatic being the last and most complex.
How do you get implants when you can't afford it?
Here are some common methods that patients use to afford dental implant procedure, most not requiring high credit scores. Healthcare installment plan. Dental insurance plan. Flexible Spending Account / Health Savings Account. Join a dental membership savings plan. Home equity line of credit. Retirement plan loan.
Does UIC do dental implants?
We treat a wide variety of dental care needs, from simple tooth decay repair and single implants to the most complex reconstructions and full mouth prosthesis. Restoring smiles– returning optimal esthetics and function to teeth — is a distinction we value.
How much does it cost to get a dental implant in Illinois?
Single Tooth Information When you need a single dental implant, it can cost between $1,000 and $3,000, but the abutment and the crown can add another $500 to $3,000. This addition makes the total between $1,500 and $6,000. This base rate is the average amount out-of-pocket.
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