Refer Your Patient

Physicians who wish to refer a patient to Emory Oral and Maxillofacial Surgery may do so by filling out the form below and pressing the Submit button to automatically send the patient's information to our office.

There is also a downloadable Referral Form (PDF, 131Kb) that can be printed and either faxed or mailed to our office. The mailing address and fax number are as follows:

Emory Oral and Maxillofacial Surgery
1365 Clifton Rd. NE
Building B, Suite 2300
Atlanta, GA 30322

Fax:  404-778-5879

As always, the referring physician or the patient is welcome to contact our office directly at 404-778-4500 in order to schedule an appointment.

Patient Information

 
* First name
Please enter the patient's first name.
* Last name
Please enter the patient's last name.
Telephone 1 ex:404-778-7777
Invalid telephone number format.
Telephone 2 ex:404-778-7777
Invalid telephone number format.
* Preferred method of contact:

Preferred method of contact is required.

Doctor's Information

 
* First name
Please enter your first name.
* Last name
Please enter your last name.
* Office telephone ex:404-778-7777
Please enter your office telephone number so we may contact you.Invalid phone format.
Email Address
Please enter your email address so we may contact you.Invalid email format.
* Preferred method of contact:

Preferred method of contact is required.
* Required