Uic referral 2026

1. Click ‘Get Form’ to open the uic referral in the editor.
2. Begin by entering the 'Date of referral' at the top of the form. This helps track when the referral was made.
3. Fill in your details under 'Referred by,' including your name and contact information (phone/email/fax).
4. Next, provide patient information: name (or parent’s name for minors), phone number, and email address.
5. Complete the 'Patient INSURANCE information' section to ensure proper billing.
6. Indicate any required procedures by checking the appropriate boxes and filling in specific details, such as teeth numbers for extractions.
7. Attach or indicate how you will send radiographs related to this referral.
8. Review medical history options and select any significant conditions or special needs.
9. Choose anesthesia recommendations based on patient needs.
10. Provide any additional comments or findings before signing off on the form with your initials and contact information.

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