Doctor Referral Form

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

Doctor Referral Form

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.

Refer To*

File Upload

Browse Files

Drag and drop files or a DICOM folder here

Accepted File Types – pdf, doc, docx, jpg, jpeg, png, gif, webp (25 MB each). X-rays & CT: DICOM files or a whole DICOM folder (bundled for you), zipped CT/CBCT exports (zip only — images and data files, no viewer programs; password-protected zips are fine), tif, bmp, stl — up to 4 GB each.

Notes / Comments

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

For Your Patient

Please share the following with the patient you are referring. These are the same directions printed on our paper referral slip.

Pre-Anesthesia Directions for IV Sedation or General Anesthesia

DO NOT EAT or drink anything for at least 8 hours prior to surgery. Water is the only exception and is ok up to 3 hours before your procedure.
Please remove contact lenses, nail polish, and excessive makeup or lipstick.
Wear comfortable, dark-colored clothing with short sleeves.
We recommend bringing a blanket, as the office can be quite cold.
Patients receiving anesthesia must be accompanied by an adult who will be present during the surgery, drive the patient home, and remain with them for 24 hours.
Patients under the age of 18 must be accompanied by a parent or legal guardian.
Notify us of any medical problems or changes in your medical history.
Bring a list of all medications and supplements to your appointment.
Take your medications as prescribed unless told otherwise.
Notify our office of any recent illness such as cold, fever, sore throat, or bowel upset prior to your appointment.

More detail is available on our Before Anesthesia page.

Additional Info / Items to Bring to Your Appointment (if available)

Driver’s license
Insurance cards
This referral or any other referrals you were provided
Valid radiographs (within one year)
Dental appliances (night guard or splint, retainer, denture, etc.)
Sleep study
Dental models

Questions before the visit? Medical Center Office: (713) 790-1995 · Memorial Office: (346) 867-3139. Directions: Medical Center Office · Memorial Office.