Confidential Sedation Referral Form Referring General Dental Practitioner DetailsName *Telephone *Practice Details *Date of Referral *Has the patient been referred previously *PATIENT DETAILSTitle *First Name *Last Name *Date of Birth *Address *Postcode *Telephone *Email AddressI Would like to refer the above patient to have treatment done under IV Sedation: (please tick) *NHS(to pay)NHS ExemptPrivateA full medical history must be attached with this referral. Please also check patient BMI (needs to be less than 35) & venous access.Medical history files *Drag and Drop (or) Choose FilesTreatment Required:(must include all relevant x-rays)Conservation *Extractions *Other treatment requiredSubmit
