Sedation referral form

This sedation form is for referral by dental professionals, with dental phobic patients who have requested conscious sedation.

If you are a patient, please call us directly.

Fill in all parts of the form before submitting.

Patient details

Your full name (required)

Address 1 (required)

Address 2

Town/City (required)

County (required)

Postcode (required)

Date of Birth (required)

Telephone - main (required)

Telephone - mobile

Email

Referral

Other reason

Treatment requested

Conservation

Left upper

Right upper

Left lower

Right lower

Extraction

Left upper

Right upper

Left lower

Right lower

Other (please specify)

Relevant radiographs attached

DPT (Max file size 1mb)

Bitewings (Max file size 1mb)

Periapical (Max file size 1mb)

Relevant medical history

Please give details of any medical conditions or medication

Referring dentist details

Full name (required)

Address Line 1 (required)

Address Line 2

Town/City (required)

County (required)

Postcode (required)

Telephone (main) (required)

Email

Confirmation



 The patient weighs less than 150kg
 The patient is aware they are being referred for treatment under conscious sedation NOT general anaesthetic
 If the patient is being referred for orthodontic extractions, a copy of the specialist orthodontist's treatment plan and relevant radiographs have been enclosed