Patient's Name

Patient's Email Address

Patient's Phone Number

Appointment Date

Preferred Office

Reason for Referral

Teeth to be Extracted

Information regarding the referral

Referring Doctor

Thank you for considering East Tennessee Oral and Maxillofacial Surgery for your patients’ surgical needs. You are welcome to fill out the form on this page to quickly get your patient into our system or printout the pdf, complete it and send it along with your patient. We have included maps to each of our seven locations on the second page of the pdf for your patient’s convenience.

If you have any questions please call us at any time.