Encino Children's Web Referral

Referral for Dental Treatment Under General Anesthesia
Patient Name

First NameLast 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

Other
Type of Work

Other
MEDICAL NECESSITY FOR ANESTHESIA (REQUIRED)

Other
EVALUATE FOR TREATMENT

Other
UPLOAD X-RAYS & TREATMENT PLAN

Cancelof
X-rays Uploaded
Treatment Plan Uploaded
Narrative (Include details on in-office treatment, behavior, x-rays & treatment plan)
Treatment subject to change on day of surgery with new clinical evaluation and X-rays.
Referring Office
Office Phone
Format: (000) 000-0000.
Doctor Recommending General Anesthesia

First NameLast Name
Doctor Signature
Patient Authorization to release HIPAA information to ECGAD (Patient Signature)

Authorization to release HIPAA information to Encino Children's (Patient Signature)
DATE

MonthDayYear
Date
Doctor
Visit our website: Encino Children's Surgery Center
Should be Empty:

Referral for Dental Treatment Under General Anesthesia