Printable Form
Please download, print and fill-out our Patient Referral Form.

After you have completed the form, please fax it to Terre Haute OMS at 812-814-9248 or

email to [email protected]

THOMS referral form

Effective August 1, 2024, Terre Haute Oral and Maxillofacial Surgery will permanently close and cease services

We understand the importance of oral surgery needs in the Wabash Valley. For future oral and maxillofacial needs, please keep in mind our Crawfordsville Oral Surgery and Plainfield Oral and Maxillofacial Surgery offices.

We thank you for your patronage for so many years and wish you all the best. 
If you have any questions, or need to obtain patient records, please email the office at [email protected]