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7151 University Blvd Unit 110, Winter Park, FL 32792
(407) 636 6003
Contact us

Center for Integrative Oral Health

ABOUT US
- CONTACT US
OUR PRACTICE
PATIENT REFERRAL
PROCEDURES
TREATMENTS
NEW PATIENT ENROLLMENT
PATIENT PORTAL
BLOG

ABOUT US
- CONTACT US
OUR PRACTICE
PATIENT REFERRAL
PROCEDURES
TREATMENTS
NEW PATIENT ENROLLMENT
PATIENT PORTAL
BLOG

© 2021.

REFERRAL FORM

DOWNLOAD AND FAX 407 636 6019 –Referral form.InOralHealth

Click download

Office location

CENTER FOR INTEGRATIVE ORAL HEALTH
7151, University Blvd, Unit 110,
Winter Park, Fl, 32792

Office Hours

Monday to Friday: 8:00 AM to 5:00 PM
Saturday: By appointment only
Sunday: Closed

Contact Info

Phone: 407 636 6003
Fax: 407 636 6019
email: info@inoralhealth.com

For a consult request, please click download and fax to 407 636 6019

Alternatively, use our online patient referral form for a consult or evaluation and management

Patient Name *

Patient's phone number *

Referring Doctor's Name *

Office Phone number *

Doctor's NPI *

Doctor's call back number *

Referral for [please check all that apply] *

Oral Mucosal lesions: Oral ulcers, Oral Lichen planus, mucositis, mucocutaneous lesions
Infectious and Inflammatory conditions, Viral, Bacterial and Fungal Infections
Temporomandibular Joint Disorders (TMD) and headaches from TMD
Orofacial pain/ trigeminal neuropathic pain/ Facial and Trigeminal Neuralgias
Dental care for Geriatric /medically complex patient
Dry mouth/ salivary gland dysfunction
Burning Mouth/ Oral Burning
Dental care for oncology patients
Oral Complications from Cancer Treatment
Bad Breath (Halitosis)
Pre /post chemotherapy consult and recommendation for safe dentistry
Pre /post radiation therapy consult and recommendation for safe dentistry
Oral evaluation for taste and smell disorders
Oral appliance therapy for Sleep apnea
other

Priority [If a timeline is not stated, referral will be treated as non urgent request] *

Urgent
Consult or E/M- non urgent
Pre surgical/ oncology treatment/ time sensitive
Critical and treatment plan pending consult

Medical history/ current Medications/ Blood test reports faxed 407-636-6019

Yes
No

Dental radiographs/ CBCT/ photographs to info@inoralhealth.com

Yes
No

Referral Note:

Email

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