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Provider Referral

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 name
Doctor/Clinic email*
Doctor/Clinic telephone*
Patient name*
Patient DOB*
Parent/Guardian name
Primary concern:*
- Initial eval
- OH exam
- OH habit
- Frenectomy
- Endo
- Other
Remarks:
Images available?*
- Yes, attached
- Yes, sent separately
- No, unavailable
Attach file/image
Accepted file types: jpg, gif, png, pdf.
Return patient after TX
- Yes
- No
Email
This field is for validation purposes and should be left unchanged.

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