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 (enter ONLY digits)*Patient name*Patient DOB (mmddyyyy)*Parent/Guardian name*Parent/Guardian Tel# (enter ONLY digits)*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 TXYesNoPlease confirm*By providing patient contact information, we confirm our patient &/or guardian has provided consent to receive correspondence from Southcenter Children’s Dentistry which may include SMS text messages (appointment reminders & general two-way communications) Msg frequency varies. Msg & data rates may apply. NOTE: No marketing messages will be sent and information is NOT shared. Patient &/or guardian may always reply HELP for support or STOP to opt out.PhoneThis field is for validation purposes and should be left unchanged.
