Conscious Sedation Referral Form

Name of the Patient*

First NameLast Name

Date of Birth*

DayMonthYear

Gender*

Contact Number:*

Area CodePhone Number

E-mail*

example@example.com

Address:*

Home Name / Number

Street Address

Town/CityCounty

Post Code

Marital Status*

Legal Guardian/Escort's Contact:*

First NameLast Name

Legal Guardian/Escort's Contact Email:*

Legal Guardian/Escort's Contact Number:*

Relationship*

Type of Referral*

UrgentRoutineReview

Type of Sedation Required*

Light IV Conscious SedationModerate IV Conscious Sedation “Twilight”Deep IV Conscious SedationInhalation Sedation N2O2 (Happy Air)

ASA Status*

1 Healthy2 Mild Medical Condition3 Multiple Medical Conditions4 Life-threatening Conditions

Medical History*

Taking any medications, currently?*

YesNo

If yes, please list it here:

Chief Complaint / Reason for Referral*

Diagnosis:*

Please include tooth nos. and/or site.

Treatment Requirement:*

What treatment would you like us to do while the patient is sedated?

Referring Clinic Name:*

Referrer’s Name:*

First NameLast Name

Referrer's GDC/GMC no.*

Referrer's Phone:*

Referrer's E-mail*

example@example.com

Referring Clinic Address:*

Home Name/Number

Street Address

Town/CityCounty

Post Code

Please verify that you are human*

Conscious Sedation Tariff

(Please advise the patient of the Conscious sedation fees before submitting a referral form)

This does not include the treatment your patient may need during sedation

Happy Air - Nitrous Oxide Relative Analgesia with Sedation Dentist - £ 280 (1 hour) +£120 succeeding 30 mins.

Light IV sedation (1 hour) with Sedation Dentist - £280

Additional 30 minutes Light IV & RA with Sedation Dentist - £120

Light IV Sedation (1 hour) with Consultant Anaesthetist - £390

Moderate IV Sedation (1 hour) with Consultant Anaesthetist - £449

Deep IV Sedation (1 hour) with Consultant Anaesthetist - £480

Additional 30 minutes Light, Moderate, Deep IV Sedation with Consultant Anesthetist - £180

WHAT TO EXPECT:

BEFORE: We endeavour to book your patient within 72 hours for assessment. Please note that we do accept patients with COPD, severe asthma, BMI of over 35 and under 12 and those with difficulty in breathing on the day of the sedation. (i.e. colds, flu and respiratory problems). There is no fasting needed.

DURING: The patient's escort (if IV sedation is needed) will attend with the patient and must show identification if they are non-related. An adult diaper will be offered as the legs will be wobbly and the patient may not reach the toilet in time. A wheelchair will be available for standby.

AFTER: The patient with an IV sedation will not be able to operate machinery, drive or fly, sign legal papers and look after animals and children within 24 hours. Please make the necessary arrangements. They may have medicines to reverse the effect of the sedation but it has a very short half-life and the effects of sedation will still be seen. There is also a possibility of retrograde amnesia whereby the patient will not remember any memories during the treatment up to the point when the medicine is wearing off.