Referring Doctors

Thank you for referring your patient to Oral Surgery Associates of Paris. Please fill out our online referral form below. You have the option to have a copy of your submission emailed to your office to document in your patient’s record.

Once you have completed our online form and attached any supporting images or documents, please click the green submit button.

Please contact our office directly by email: info@oralsurgeryap.com

Online Referral Form

Click this box to upload any supporting images or files.

Patient Information

First Name Last Name Phone Number Email Address Please reach out and contact this patient:

Street Address City State Zipcode

Referring Doctor Information

Referring Doctor and Practice Referring Practice Email
(A copy of this form will be sent to this email as confirmation) Referring Practice Phone Number

dental PPO insurance

Dental PPO Insurance Carrier Insurance Phone number Relationship to Patient

Subscriber Name Subscriber ID Subscriber DOB

Patient Evaluation

Extractions Dental Implants Expose and Bond Teeth #'s Pathology Maxillofacial Injury

Anesthesia Preference: Nature of Referral and Other Important Information
Submit referral