ABLE FAMILY DENTAL PATIENT REFERRAL FORM

Patient Information
Able Family Dental accepts referrals for dental implants, orthodontic treatment (traditional braces or Invisalign®), and intravenous (IV) sedation. Please select the service(s) requested below and complete the referral information. Additional acknowledgement is required for IV sedation referrals.
Referred for the following:
IV Sedation Acknowledgement
Able Family Dental offers Intravenous Sedation for patients 12 years of age or older. Patients must have a BMI of 40 or less and be ASA Classification 1, 2, or 3. ASA 3 patients may require that the doctor consult with the patient's primary care physician or consulting medical specialist in situations with significant medical considerations or where the control of those conditions is unclear. ASA 4 patients are not permitted to be sedated by a Regulated Member using this technique.
I confirm that, to the best of my knowledge, the patient being referred meets the above criteria, or that any significant medical considerations have been disclosed in this referral.
Preferred Dentist:
Name of Patient:
Gender as listed on insurance:
Name of Guardian:
(if applicable)
Patient Email:
example@example.com
D.O.B:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of birth
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone (Home):
Please enter a valid phone number.Format: (000) 000-0000.
Phone (Cell):
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Information

Primary Insurance
Insurance Carrier:
Policy Holder:
D.O.B:

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate of birth
Group/Plan No:
Cert No/ID No:
Secondary Insurance
Insurance Carrier:
Policy Holder:
D.O.B:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate of birth
Group/Plan No:
Cert No/ID No:
Referred for the following:
Other Notes:
Referral Information
Referred By Dr:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Referral Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Email:
example@example.com
Attach File(s): Treatment Plan, X-Rays and Medical Form:

(Allowed file types are doc, jpg, png, gif, pdf, maximum total file size 10MB)
Cancelof
OR
I confirm that, to the best of my knowledge, the patient being referred meets the above criteria, or that any significant medical considerations have been disclosed in this referral.
Dental Office:
Able Family Dental
511, 5th Street South
Lethbridge, Alberta T1J 2B9
T: 403-327-7202
F: 403-327-7220
reception@ablefamilydental.com
Should be Empty:

Patient Information

IV Sedation Acknowledgement

Insurance Information

Referral Information