Referral for Dental Treatment Under General Anesthesia
Patient Name
*
First Name
Last Name
Patient's Date of Birth
*
Patient Phone
*
Patient Alternate Phone
Patient's Dental Insurance
Dental Insurance Subscriber #
Primary Language
English
Spanish
Other
Type of Work
Pediatric
Special Needs
Other
MEDICAL NECESSITY FOR ANESTHESIA (REQUIRED)
*
Use of local anesthesia to control pain failed or was not feasible based on medical needs of patient
Use of conscious sedation, either inhalation or oral, failed or was not feasible based on the medical needs of the patient.
Use of effective communicative techniques and the inability for immobilization (patient may be a danger to self or staff)
Patient requires extensive dental restorative or surgical treatment that cannot be rendered under local anesthesia or conscious sedation
Patient has acute situational anxiety due to immature Cognitive Functioning
Patient is uncooperative due to certain physical or mental compromising conditions
Other
EVALUATE FOR TREATMENT
SSCs
SSCs + Pulp
Ext
RCT
Fillings
Other
Additional treatment notes
UPLOAD X-RAYS & TREATMENT PLAN
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X-rays Uploaded
*
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Treatment Plan Uploaded
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Yes
No / Unable to obtain
Patient Authorization to release HIPAA information to ECGAD (Patient Signature)
Authorization to release HIPAA information to Encino Children's (Patient Signature)
Referring Office
*
Office Phone
*
Doctor Recommending General Anesthesia
*
First Name
Last Name
Doctor Signature
*
DATE
/
Month
/
Day
Year
Date
Doctor
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Encino Children's Surgery Center
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