For Referring Doctors

Physician referral forms are located here. Please use one of the following forms to refer a patient to Carolinas Center For Oral & Facial Surgery.

General Referral Form

Download NC Referral Form

This is the General Referral Form. Fill out and submit this PBHS form for all of your patient referrals to us. (Opens in new tab). You may also download the .PDF and send it in via fax or email.

Orthognathic Referral Form

Download NC Orthognathic Referral Form

This is the Orthognathic Referral Form. Please use this form to refer Orthognathic patients to our practice. (Opens in new tab). You may also download the .PDF and send it in via fax or email.

TMJ Referral Form

Download NC TMJ Referral Form

This is the TMJ Referral Form. Please use this form to refer TMJ patients to our practice. (Opens in new tab). You may also download the .PDF and send it in via fax or email.

Dental Implants Referral Form

Download NC Implant Referral Form

This is the Dental Implant Referral Form. Please use this form to refer dental implant patients to our practice. (Opens in new tab). You may also download the .PDF and send it in via fax or email.

Envision Referral Form

Download Envision Referral Form

**NEW** This is the Envision Implant Referral Form. Please use this form to refer dental implant patients to our practice. (Opens in new tab). You may also download the .PDF and send it in via fax or email.

*Use of these links and submission of information is subject to the HIPPA Notice of Privacy Practices. Submission of information should be seen as an acknowledgement of each patient’s rights under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Opens in new tab).

Referral Forms

For Referring Doctors