Contact the Oral and Maxillofacial Surgery Program

Thank you for choosing CHOP Oral Surgery Department to participate in the medical care of your patient.

For patients, call us at 215-590-1563 to schedule an appointment with us.

For medical and dental practices, please submit the following information below.

When providing specific information on your patient’s teeth, please refer to this visual.

Patient first name:

Patient last name:

Patient DOB (mm/dd/yyyy):

Referring Physician name:

Referring Physician phone number:

Referring Physician address:

Country

Address 1 *

Address 2

City *

State *

ZIP code *

Treatment request:

Descriptions on teeth:

Please refer to the visual above.

Leave this field blank