Refer a Patient

This form is for referrals only. If you are the patient, please call 617-726-2740 to speak with a representative.

Please submit the secure form below to refer your patient to a provider in the Division of Oral and Maxillofacial Surgery and Dentistry. This form should not be used for appointments needed within 72 hours. In those cases, please call us at 617-726-2740.

After you submit this form, our office will work directly with the patient to schedule an appointment and assist with registration if needed. Referring providers will be notified of appointment details. You may also speak with a representative directly Monday – Friday, 8:00 am to 5:00 pm EST by calling 617-726-2740.

Important note: Some questions on this form may appear or disappear based on your responses.

* indicates a required field.

Patient Information

First name

Last name

Date of Birth

MM/DD/YYYY

Phone number (to contact the patient with appointment information)

To facilitate processing, please provide insurance plan name if known

Is the patient aware of this referral?

YesNo

Reason for referral

Please specify

Implant site numbers

Which teeth need to be extracted?

What is the tooth number?

Describe reason for referral and include ICD10 code if known

Has imaging been performed in the last six months for this patient's condition?

YesNo

If yes, please send all digital copies of imaging to omfsimages@partners.org. If unable to send digitally, please mail them to Mass General Hospital, OMFS Department, 55 Fruit Street, Wang 230, Boston, MA 02114.

Referring Physician

First name

Last name

Phone

Fax

Practice name

National Provider Identification (NPI) Number

Address line 1

Address line 2

City

State

Zip Code

Additional Comments

The Mass General Difference

Conditions & Treatments

Patients & Visitors

Research & Innovation

Oral & Maxillofacial Surgery

Refer a Patient

Refer a Patient