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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:
First Name is required.
* Last Name
Last Name is required.
Telephone 1: ex:404-778-4500
Phone number is required.Invalid phone format.
Telephone 2: ex:404-778-4500
Phone number is required.Invalid phone format.
* Preferred method of contact:

Preferred method of contact is required.
Referring Physician
* Physician Name:
Physician name is required.
* Phone: ex:404-778-4500
Physician phone number is required.Invalid phone format.
Email Address
Invalid email format.
* Preferred method of contact:

Preferred method of contact is required.
* Please evaluate for the following:
Please select an item.
* X-rays:
Please select an item.
* Required