Patient Referral Form - Dentist To Physician - Blue Cross Blue Shield Of Michigan
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1Patient Referral Form – Dentist to Physician
Patient name: ______________________________
Daytime phone:
___________________________
Referral date: _____________________
Patient referred by:
Dr. ____ ____________________________________
Office phone:
_____________________
Patient referred to:
Dr. ____ ____________________________________
Patient has appointment on:
Date:______________ Time:__________
Patient will call and schedule an appointment.
During a recent oral and maxillofacial examination, we were alerted to the possibility of this patient having
a positive medical history or signs and symptoms of the following:
Diabetes mellitus
Kidney dialysis
Joint replacement
Organ transplant
Head and neck radiation
Pregnancy
Bisphosphonate therapy
Chemotherapy
Cardiovascular disease (hypertension,
Gastroesophageal reflux disease
stroke, myocardial infarction, other)
Other______________________
We are referring this patient to you for a thorough medical evaluation and are requesting any additional
medical information to assist us in managing the patient when he or she undergoes dental treatment.
Dental treatment planned:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Contraindications to the planned procedures based on your physical findings or the patient’s medical
history (please indicate all of this patient’s diagnoses):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Note: There is no guarantee that recommended treatment is a covered benefit.
We will delay dental procedures, pending your written recommendations. Thank you for your efforts on
behalf of this patient.
WHEN COMPLETED
Physician signature: _____________________________ Date evaluation completed: _______________
Patient: Please return form to referring dentist.
Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.
WF 10355 DEC10
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