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Special Healthcare Needs Clinic Referral Form

Referring Doctor

Urgency*

 Routine         Urgent         Clearance

Patient Information

Patient Insurance

Provide ALL insurance for both medical and dental so we can appropriately coordinate benefits and/or provide prior authorization as needed.

Appointment Information

Patient must call to schedule: Please wait 5-6 business days to call and schedule to ensure adequate time to process referrals.



Patient will need an interpreter.

Patient has special needs.

Patient interested in sedation*   Yes      No
*IV sedation is not offered.



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UR
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UL

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LR
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Comments

All imaging is required for review. Upload imaging in attachments below.

  • If there is no imaging, please state in the comments below.

Attachments

Maximum size for attachment: 15MB

Images

Upload x-rays, patient photos, and patient insurance card(s) for our staff to review. Please click the choose file button and select the image file. Then enter the date the image/photo/insurance card was captured. Finally click the blue 'Add' button. If your file was successfully added it will appear in the table below



Image Name Date Taken
None added

Documents

If you would like include a document for our staff to review please click the choose file button and select the apporiate document. If you would like to upload multiple items, please follow the process to compress the items into one '.zip' file. Then click the choose file button and select the '.zip' file.

University of Minnesota Dental Clinics
515 Delaware Street SE, 16-205 Moos Tower
Minneapolis, MN 55416
P: (612) 625-2495
F: (612) 624-7960