MAKE A REFERRAL

Make A Referral

If you want to refer one of your patients for a procedure at our practice, please fill out the following form and we will get back to you and/or your patient about scheduling an appointment.

Referral Information

Surgeon

Location

Procedure Details

Primary Concern(s):

Dental Extractions

Third Molars

Tooth Exposure

Dental Implants

Procedure Type(S):

Bone Augmentation

Pathology/Biopsy

Orthognathic Surgery

Temporomandibular Joint Disorder

Three Dimensional Imaging

site(s):

55

54

53

52

51

18

17

16

15

14

13

12

11

61

62

63

64

65

21

22

23

24

25

26

27

28

41

42

43

44

45

46

47

48

81

82

83

84

85

38

37

36

35

34

33

32

31

71

72

73

74

75

Patient Information

d.o.b.://

Patient Details

Anesthetic Preference:

Local

Sedation

General

Radiograph:

Emailed

Enclosed

Please Take

Get In

Contact

Our goal at Maxillo Winnipeg is to ensure our patients receive safe and comfortable treatment in a fully accredited surgical facility.

MAKE A REFERRAL

HENDERSON

755 HENDERSON HWY

SUITE 303

WINNIPEG, MB

R2K 2K5

CANADA

PORTAGE

2305 PORTAGE AVE

WINNIPEG, MB

R3J 0M6

CANADA