Patient Referral Form - Dentist To Physician - Blue Cross Blue Shield Of Michigan

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Patient 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
Bisphosphonate therapy
Cardiovascular disease (hypertension,
Gastroesophageal reflux disease
stroke, myocardial infarction, 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.
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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