Get Uic Oral Surgery

The Uic Oral Surgery referral form is essential for facilitating the surgical care of patients at the University of Illinois at Chicago College of Dentistry. This guide provides clear, step-by-step instructions to help you successfully complete the form online.

Follow the steps to efficiently complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date of referral in the designated field at the top of the form. This serves as the official date of the referral.
3. Fill in the 'Referred by' section with your name and relevant details to identify the referring individual.
4. Provide your office phone, email, and fax number in the corresponding fields, ensuring accurate contact information.
5. Input the patient's name or parent’s name (if the patient is a minor) in the appropriate section.
6. Enter the patient's date of birth (DOB) in the specified format.
7. Add the patient's primary phone number and, if applicable, an alternative phone number for better communication.
8. Include the patient's email address to facilitate future correspondence.
9. Fill out the patient insurance ID number and name to ensure billing accuracy.
10. Indicate the needed surgical procedures by checking the appropriate boxes, such as extraction of specific teeth and other surgical options.
11. If dental radiographs are available, select how they will be submitted: attached, emailed, sent by mail, or if none are available.
12. Provide any relevant medical history details by checking the appropriate options for negative or significant medical conditions and special needs.
13. Choose anesthesia recommendations based on the patient's needs by marking the applicable options provided in the form.
14. Indicate any facial injuries, swelling, or other findings in the designated area to inform the oral surgery team.
15. Complete the 'Other/Comments' section with any additional information that may assist in the referral process.
16. Enter the name of the person completing the form, along with their contact phone, fax, and email information.
17. Sign the form by providing your initials in the signature area to confirm the validity of the referral.
18. Once all sections are completed, save the changes, and ensure the form is ready for submission.

Complete the Uic Oral Surgery referral form online today to ensure timely and effective patient care.