Referrals Please use the form below to refer a new patient: Prairie Periodontics Dr. Sarah Gallagher 100-1202 Emerson Ave. Saskatoon, SK S7H 2X1 (306) 664-1931 reception@prairieperiodontics.caReferred byClinic NameDate DD slash MM slash YYYY We are referringPatient Name First Last Patient D.O.B. DD slash MM slash YYYY Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Primary Phone #Secondary Phone #Parent / Guardian First Last Email Dental Plan 1 Primary Insurance Subscriber Name Birth Date DD slash MM slash YYYY Dental Plan 2 Secondary Insurance Subscriber Name Birth Date DD slash MM slash YYYY Reason for Referral Comprehensive Periodontal Examination and Treatment Soft Tissue Grafting Implant Placement/Bone Grafting Implant Preference, if any Implant Preference Extraction/Ridge Preservation Crown Lengthening Frenectomy Other CommentsMedical HistoryPlease send all radiographs taken within the last two years of all areas of the mouth (regardless of subject of referral). Please include the dates taken in the field below.Upload Files Drop files here or Select files Max. file size: 30 MB. Please type in dates taken(Required)Please type in dates taken.
