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.
Child above 12 years ageAdult
Your full name (required)
Address 1 (required)
Date of Birth (required)
Telephone - main (required)
Telephone - mobile
Other (please specify)
DPT (Max file size 1mb)
Bitewings (Max file size 1mb)
Periapical (Max file size 1mb)
Please give details of any medical conditions or medication
Full name (required)
Address Line 1 (required)
Address Line 2
Telephone (main) (required)
The patient is over the age of 12 - unless suffering from acute pain/sepsis
The patient is ASA1 or ASA2
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
I hereby give consent to contact me using the information I have provided.