GP Referrals

Fill out the referral form below to refer your patient to a plastic surgeon or dentist at Southgate Surgical Suites in Lethbridge.

Select a Doctor

Referring To: *

Dr. James Evanson (5th Avenue Dental Clinic) Dr. Shawn Heggie (Ivory Dental) Dr. John Hasell Dr. Matthew Secretan Dr. Michael Evans Dr. Tim Rollingson Other Not Sure

Patient Information

Patient Name: *

Parent's Name:

Email Address: *

Date of Birth: *

Address: *

Telephone: *

Insurance Information

Subscriber Name: *

Subscriber D.O.B.: *

Insurance Company: *

Subscriber Group #: *

Subscriber ID #: *

Reason for Patient Referral: *

Medical History: *

Additional Information

Date: *

Referring Doctor: *

X-Rays Available? *

Yes

No

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