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 on 01638 577 031.

Fill in all parts of the form before submitting.

    Patient details

    Reason for the referral

    Conservation treatment requested

    Extraction requested

    Relevant radiographs attached

    Relevant medical history

    Referring dentist’s details


    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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