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.

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Patient Information


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

Referring Physician