Referral for Dental Treatment Under General Anesthesia
Patient Name
*
First Name
Last Name
Patient's Date of Birth
*
Patient Phone
*
Format: (000) 000-0000.
Patient Alternate Phone
Format: (000) 000-0000.
Patient's Dental Insurance
Dental Insurance Subscriber #
Primary Language
English
Spanish
Other
Type of Work
Pediatric
Special Needs
Oral Surgery
Other
MEDICAL NECESSITY FOR ANESTHESIA (REQUIRED)
*
Patient has documentation of failed in-office sedation (e.g. nitrous oxide)
Patient is 2-7 years old AND in-office dental treatment could not be completed due to behavior
Patient is 8-17 years old AND is extremely uncooperative/fearful/uncommunicative AND has significant dental needs such that treatment should not be delayed AND in-office dental treatment is not appropriate
Patient has developmental disability/medical condition that prevents in-office treatment
Patient has impacted wisdom teeth
Other
EVALUATE FOR TREATMENT
SSCs
SSCs + Pulp
Ext
Fillings
RCT (apex must be closed)
Additional treatment notes
UPLOAD X-RAYS & TREATMENT PLAN
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X-rays Uploaded
Yes
No
Treatment Plan Uploaded
Yes
No
Patient Authorization to release HIPAA information to CCGAD (Patient Signature)
Authorization to release HIPAA information to Capital Children's (Patient Signature)
REFERRING OFFICE
*
OFFICE PHONE
*
Format: (000) 000-0000.
Doctor Recommending General Anesthesia
First Name
Last Name
Doctor Signature
*
DATE
/
Month
/
Day
Year
Date
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