UM School of Dentistry External Referrals Feedback Form

Thank you in advance for your feedback...
If the referral form you’re filling out isn’t working as expected, you should check the following:

  • You're using the most current version of your browser
  • The following browsers are recommended:  Chrome (preferred), Edge, Safari, Firefox 
  • Computer is running the current version of Windows 10 or Mac OS 10.14 and above
Please do not put Personal Health Information in this form.

Ticket Details

What kind of assistance do you require?
Which clinic referral are you providing feedback for?
This information will help us determine the problem
No patient ID nor Patient Health Information - What is the problem you’re having? Please provide enough detail for us to address the issue.
Press Alt + 0 within the editor to access accessibility instructions, or press Alt + F10 to access the menu.
File attachments associated with the ticket.

Contact Information

Other Fields

Your name
Verification Code