Provider Referral Printable Version MAIL to: 411 Strander Blvd, Ste 303 Tukwila, WA 98188 FAX to: (206) 575-1133 Provider Referral Submit Below Doctor name*Clinic nameDoctor/Clinic email*Doctor/Clinic telephone*Patient name*Patient DOB*Parent/Guardian namePrimary concern:* Initial eval OH exam OH habit Frenectomy Endo Other Remarks:Images available?*Yes, attachedYes, sent separatelyNo, unavailableAttach file/imageAccepted file types: jpg, gif, png, pdf.Return patient after TXYesNoEmailThis field is for validation purposes and should be left unchanged.