Patient Referral Form

425.392.4888

New Patients

Dr. Referrals

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Home
Our Practice
SANO Method
Infant+Children
Teens+Adults
Treatments
Financials
- Personalized Strategies
- Third-Party Financing
Resources
Contact Us

Please complete the form below to refer a patient to AirSync

Thank you! We will contact the patient and keep you updated on their care.

Patient’s Name (required)

If patient is a minor, parent’s name (required)

Patient’s Age or Birthdate:(required)

Email:

Phone number:

Reason For Referral (required)

Infant Tongue-Tie BabyLase Child / Adult Tongue-Tie Toddler / Child Airway Construction (Early Intervention) Pre-Teen / Teen / Adult Airway Construction + Airway Orthodontics Early Intervention Expansion (orthodontics being done elsewhere) MARPE Expansion (orthodontics being done elsewhere) Migraines + Headaches TMJ Disorders Nonsurgical treatment of enlarged tonsils/adenoids Impaired nasal breathing Chronic sinus issues, post-nasal drip, chronic congestion Snoring Mouth breathing CPAP Intolerance Patient wants to get off CPAP Sleep Apnea diagnosis and patient wants to get better Oral Myofunctional Therapy Exomind TMS for mental wellness, ADHD, anxiety, depression EmFace for TMJ EmFace for nonsurgical esthetics Emsella for pelvic floor dysfunction and core strengthening Other

If you answered "other" please list the reason here:

Referring Provider Information (required)

Home
Our Practice
SANO Method
Infant+Children
Teens+Adults
Treatments
Financials
- Personalized Strategies
- Third-Party Financing
Resources
Contact Us

Home
Our Practice
SANO Method
Infant+Children
Teens+Adults
Treatments
Financials
- Personalized Strategies
- Third-Party Financing
Resources
Contact Us

425.392.4888

New Patients

Dr. Referrals

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