Online Referral Form

Secure Online Doctor Referral Form

You may refer patients to NRV Oral & Maxillofacial Surgery, Ltd. by filling out our secure online Referral Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. After you submit the form you will have the opportunity securely upload and transmit images of Patient X-rays.

Clickable button to launch a secure, online Oral Surgery Doctor Referral form

The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it.

For assistance, please call our office: NRV Oral & Maxillofacial Surgery Blacksburg Office Phone Number 540-951-8777 (Blacksburg) or NRV Oral & Maxillofacial Surgery Radford Office Phone Number 540-633-5700 (Radford).