Provider Referral PRINT CLICK TO PRINT SUBMIT FORM SEND PRINTED REFERRAL: Mail: 411 Strander Blvd, Ste 303 Tukwila, WA 98188 Fax: (206) 575-1133 Email: southcenterkids@dentalmail1.com _________________________________________ Doctor name*Clinic nameDoctor/Clinic email*Doctor/Clinic telephone*Patient name*Patient DOB*Parent/Guardian name*Parent/Guardian Tel#*Primary concern:* Initial eval OH exam OH habit Frenectomy Endo Restorative Other Remarks:Images available?*Yes, attachedYes, sent separatelyNo, unavailableAttach file/imageAccepted file types: jpg, gif, png, pdf.Return patient after TXYesNoNameThis field is for validation purposes and should be left unchanged.
