THIS SITE IS CURRENTLY UNDERGOING MAINTENANCE
During this time, the referral forms may not funciton as expected.
Estimated Completion: 3:00pm EST

Hospital-Based and Integrated Special Care Dentistry

Read This First

HD/ISCC does not offer IV sedation services.

1. Doctor Information

(required)
letters, spaces, hyphens, apostrophes
(required)
letters, spaces, hyphens, apostrophes
(required)
letters, spaces, hyphens, apostrophes

numbers only, 10 digits required, or 15 if using prefix 80840
(required)
numbers, hyphens
(123-123-1234)
(required)
numbers, letters, hyphens, apostrophes
([email protected])
(required)
numbers, letters, spaces, hyphens, apostrophes
(required)
numbers, letters, spaces, hyphens, apostrophes
(required)
Only U.S. States are currently available
(required)
numbers, hyphen
(format: 12345 or 12345-6789)
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

(required)
letters, spaces, hyphens, apostrophes
(required)
letters, spaces, hyphens, apostrophes
(required)
numbers, hyphens (ex: 01-25-1997)

optional

numbers, letters, hyphens, apostrophes

numbers, letters, hyphens, apostrophes
(required)
please select one

numbers, letters, hyphens, apostrophes
(required)
numbers, letters, spaces, hyphens, apostrophes
(required)
numbers, letters, spaces, hyphens, apostrophes
(required)
Only U.S. States are currently available
(required)
numbers, hyphen
(format: 12345 or 12345-6789)
(required)
numbers, hyphens
(123-123-1234)

numbers, letters, hyphens, apostrophes
([email protected])

3. Procedures and Imaging *

Required if there is a guardian
Required if there is a guardian
Required if there is a guardian

Please list all of patient’s active medical diagnoses and/or current medical problem list. A comprehensive list helps staff determine the most appropriate clinic setting for treatment.

Reasons


Management of anxiety alone does not qualify for referral to HD/ISCC

What service or modification can we provide to the patient that would facilitate safe and adequate treatment?
(Example: accommodations for wheelchair: patient unable to transfer.)
HD/ISCC do not currently offer IV sedation services for comprehensive dental treatment.

Image Uploads

(required) Accepted File Types: jpg, jpeg, png, gif, pdf, docx, dcm
For all uploads, please choose a relevant date for each radiograph or document
(Upload examples: Clinical/chart notes, guardianship papers, face sheets, and/or radiographs)
Add File or Image

If there are questions about the appropriateness or guidance related to this referral is requested, please send an email to this secure address [email protected], and one of our team members will respond as soon as possible.