Referral Form

Thank you for choosing Gateway Oral & Maxillofacial Surgery as your office of choice. Please fill in the required information, then continue by adding any radiograph image file (.jpg, .bmp or .tif) to be submitted.

You can also print a referral form to fax to the office at 780.760.1502 by clicking Launch PDF button.
(To view form, you will need an Adobe Acrobat Reader installed.)


Patient's Name:

Please enter the patient's name.
Patient's Telephone number:

Please enter the patient's telephone number.
Patient's Email (if available):

Referring Doctor's Name:

Please enter the referring doctor's name.
Doctor's Telephone number:

Please enter the referring doctor's telephone number.
Doctor's Email (for receipt):

Please enter the referring doctor's email address.


Please click on the teeth to be treated

Please indicate teeth or quadrant to be treated by clicking on tooth to highlight blue



Procedure



Radiograph



Attach X-Ray

Browse for the X-Ray file on your computer and click the "Attach" button to attach it to your submission.



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Referral Form

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