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 MCGAD (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
2 digit month, 2 digit day, 4 digit year
Date
Physician
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otownchildrens.com
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