Online Referral Form

Thank you for trusting us to take exceptional care of your patients!  In an effort to provide you with a convenient way to contact us, we offer you several ways to refer patients to Southwest Florida Oral & Facial Surgery.

  • Fill out our secure online Referral Form below. After you have completed the form, please make sure to press the ‘Complete and Send’ button at the bottom to automatically send us your information. You will be given the option to download a copy of the referral for your records as well as attach digital patient x-rays. The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it.
  • Call our offices at 239-936-8151 (Fort Myers) or 239-772-5377 and speak to anyone from our dedicated front office team to schedule your patient with us.
  • Send a printed Referral Form with your patient.  You may print a blank Referral Form from the link below or you are welcome to call our Fort Myers office at 239-936-8151 or our Cape Coral office at 239-772-5377 to request that Referral Forms be sent to you.
  • Fax the Referral Form to 239-936-9103 (Fort Myers) or 239-772-0807 (Cape Coral).  If you prefer to email the Referral Form and digital x-rays, please send to Courtney at [email protected].

For Doctor Use only

Referral Form