Sedation Referral Form

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

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I hereby give consent to contact me using the information I have provided.

Patient Details

Reason for the referral

Conservation treatment requested

Extraction requested

Relevant radiographs attached

Relevant medical history

Referring dentist’s details

Confirmation