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
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 (please include brief narrative)
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 treatment is not appropriate (please include brief narrative)
Patient has developmental disability/medical condition that preventsin-office treatment (please include brief narrative)
Other Circumstances (please describe in detail):
EVALUATE FOR TREATMENT
SSCs
SSCs + Pulp
Ext
Fillings
Other
Narrative (Include details on in-office treatment, behavior, x-rays & treatment plan):
UPLOAD X-RAYS, TREATMENT PLAN & PROGRESS NOTES
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X-rays Uploaded
*
Yes
Unable to obtain (please include brief narrative)
Treatment Plan Uploaded
*
Yes
Unable to obtain (please include brief narrative)
Patient Authorization to release HIPAA information to MC GAD (Patient Signature)
Authorization to release HIPAA information to Motown Children's (Patient Signature)
Referring Office
*
Office Phone
*
Format: (000) 000-0000.
Physician Recommending General Anesthesia
*
First Name
Last Name
Physician Signature
*
DATE
/
Month
/
Day
Year
Date
Physician
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otownchildrens.com
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