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

DISCLAIMER: Ensuring the accuracy and completeness of the information provided in this form is essential for delivering timely and appropriate care to the patient. *
● HD/ISCC does not offer IV sedation services

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.

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. Guardianship

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

4. Patient Medical History & dental information

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.

Examples may include clearance for initiating hemodialysis, organ transplant, or chemotherapy.

  • Administration of blood products or transfusion during treatment
  • Continuous cardiac monitoring
  • General anesthesia for dental care

ToolTips:

  • 1. Administration of blood products or transfusion during treatment: administration of blood products such as red blood cells or platelets for treatment.
  • 2. Continuous heart monitoring: real-time tracking of heart activity during care to detect irregularities.
  • 3. General anesthesia: a medication-induced sleep state used during procedures to block pain and awareness.

Image Uploads

(required) Accepted File Types: jpg, jpeg, png, gif, pdf, docx, dcm
Only .jpeg files are accepted for images/radiographs
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