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
nd
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
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Enter Clinical Sciences Building at 521 Parnassus (across the street from the Library)
•
th
Take the elevator on your right to the 6
floor
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Make a right out of the elevator and go down the hall to Room C646 (last door on left)
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