Referral Form printable pdf download

Referral Form

UCSF

University of California San Francisco

ORAL MEDICINE CLINICAL CENTER

Oral Medicine Clinic  Oral AIDS Center  Sjögren’s Syndrome Clinic

521 Parnassus Avenue, ROOM C-646, San Francisco, CA 94143-0422

Phone: 415/476-2045

Fax: 415/514-2862

Referral Form

Referring Clinician Name:

Phone #:

Fax #:

Patient Name:

Phone #:

Chief Complaint:

Oral Examination Findings (please briefly describe lesion character, color, and location. Use

mouth diagram below if necessary)

Oral lesion location

(circle area on diagram)

Please attach any pertinent biopsy and/or clinical laboratory report, and radiographs, and

ask patient to bring these documents and this form to his/her Oral Medicine appointment

(you may also fax the documentation to 415/514-2862 prior to appointment. This fax

machine is located in a secure area restricted to clinic personnel).

Signature of Referring Clinician: __________________Date:__________________

Directions to the Oral Medicine Clinical Center from public parking garage

Public parking for UCSF Medical Center accessible from Irving Street / 2

Avenue

•

Take public parking elevator to J – level

•

Access Parnassus street level by stairs, or elevator located behind staircase

•

Enter Clinical Sciences Building at 521 Parnassus (across the street from the Library)

•

Take the elevator on your right to the 6

floor

•

Make a right out of the elevator and go down the hall to Room C646 (last door on left)

•

Referral Form