Doctor Referral Form

Refer a patient to Lighthouse Oral & Maxillofacial Surgery. Submit the details below and our team will follow up promptly.

Please complete the fields below to refer a patient to our practice. Our team will reach out to schedule a consultation.

Thank you — the referral was submitted successfully. Our team will follow up shortly.

Patient Name*

First Name Last Name

Patient Phone*

Please enter a valid phone number.

Referring Doctor Name*

First Name Last Name

Referring Doctor Email*

Please enter a valid email address.

Insurance Card

Browse Files

Upload a photo of the front and back of the patient's insurance card

Accepted File Types – jpg, jpeg, png, gif, pdf

File Upload

Browse Files

Drag and drop files here

Accepted File Types – pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif

Notes / Comments

Fields marked with * are required. Your information is sent securely to our office.