Online TMJ Referral Form – Refer Patients for TMJ Evaluation & Orofacial Pain Care

Introduction:

At the Boston Center for Oral Health (BCOH), we understand the complex and often debilitating nature of temporomandibular joint (TMJ) disorders. Our specialized team provides comprehensive evaluations and treatment options for patients experiencing TMJ-related symptoms, including jaw pain, joint dysfunction, headaches, orofacial pain, and sleep-disordered breathing.

To better serve our referring providers and their patients, we’ve created this secure online referral form—making it easier than ever to collaborate with our TMJ-focused care team. Whether you’re a dentist, physician, or the patient is self-referred, this form allows for fast, accurate information sharing and seamless case coordination.

About the Form:

The TMJ Online Referral Form is designed to gather all relevant patient history, symptom details, imaging, and provider information needed to begin evaluation and care planning. The form is HIPAA-compliant and allows providers to securely upload imaging, clinical notes, and supporting documentation. Our TMJ team reviews referrals promptly and contacts the patient directly for next steps.

Form Sections Overview:

• Referral Reason
  Choose from TMJ Evaluation, Orofacial Pain, Suspected Joint Dysfunction, Sleep Disordered Breathing related to TMJ, or specify another concern.
• Patient Information
  Includes the patient’s name, DOB, contact info, address, and their current dental provider if known.
• Symptoms & History
  Gathered from the referring provider or self-referred patient—covering primary complaints, onset, prior treatments, and associated symptoms like headaches, tinnitus, or sleep apnea.
• Imaging
  Indicate any existing imaging (Panoramic X-ray, CBCT, MRI) and provide dates and results summaries if available.
• Medical History
  Includes relevant conditions such as arthritis, autoimmune issues, trauma, or medications impacting TMJ health.
• Referring Provider Information
  Contact details, clinic name, NPI number, and referral date.
• Uploads
  Attach clinical notes, imaging files, treatment records, or a formal referral letter in secure formats (PDF, JPG, DOC).
• Referral Notes
  Free-text field to communicate specific questions or concerns for the BCOH TMJ team.
• Consent Confirmation
  Option to confirm the patient has given permission to share their information.