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Get Uic Referral Form

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

  1. Click ‘Get Form’ button to obtain the form and open it in a digital editor.
  2. Enter the date of referral in the designated field at the top of the form.
  3. Provide your name as the referring practitioner, along with your office phone number, email, and fax information.
  4. 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.
  5. Detail the patient's insurance information in the relevant section.
  6. Indicate the required dentoalveolar surgery, marking the relevant checkboxes and providing specific tooth numbers when necessary.
  7. If needed, specify any additional procedures such as alveoplasty, incision and drainage, or biopsy, amongst others.
  8. Include any dental implant numbers or pathology details in the provided fields.
  9. For orthognathic evaluation and TMJ evaluation, briefly describe the requirements.
  10. Identify whether radiographs are attached, to be sent by email or mail, or indicate if none are available.
  11. Provide information regarding the patient's medical history, noting if it is negative or detailing any significant issues or special needs.
  12. Choose anesthesia recommendations appropriate for the procedure.
  13. Complete any other comments or additional instructions in the provided space.
  14. Finally, enter your name, signature or initials, phone, fax, and email as the person completing the form.
  15. 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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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.

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.

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.

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.

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.

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.

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.

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.

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.

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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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232