(780) 761-6671

Refer a patient

Dr. Major can help your patient with obstructive sleep apnea, braces, Invisialign, TMD and orthodontic treatment. Fill out the form below to refer your patient to Dr. Michael Major.

Refer a patient

Dr. Major can help your patient with obstructive sleep apnea, braces, Invisialign, TMD and orthodontic treatment. Fill out the form below to refer your patient to Dr. Michael Major.

Referring Patient Info

Patient's First Name

Patient's Email

Patient's Last Name

Patient's Phone Number

Patient's Address

Patient's Address 2

Patient's Province

Patient's Postal Code

Referring Doctor Info

Referring Doctor's First Name

Referring Doctor's Last Name

Referring Doctor's Office Phone

Referring Doctor's Office Email

Please Evaluate For

Crowding

Spacing

Class II

Class III

Deep Bite

Open Bite

Crossbite

Impacted Teeth

Airway / Sleep Apnea

Early / Interceptive

Pre-prosthetic

Invisalign

Radiographs Available

PANOREX

Date for Radiographs

CEPHALOGRAM

Date of Last Dental Cleaning

PERIAPICALS

Additional Remarks

Appointment Arrangements

Contact Patient at

Insurance Arrangements

Policy Holder's FIrst Name

Insurance Company

Policy Holder's Last Name

Group / Plan / Policy #

Policy Holder's Birth Date

ID / Cert #

Send Referral

Dr. Michael Major

(780) 761-6671

[email protected]

5540 Windermere Blvd #201 Edmonton, AB T6W 2Z8

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