Referral for Dental Treatment Under General Anesthesia
Patient Name
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First Name
Last Name
Patient's Date of Birth
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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)
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Patient is 2 - 6 years old AND requires multiple extractions or multiple restorations.
Patient is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative, with dental needs of such magnitude that treatment should not be postponed or deferred. Lack of treatment can be expected to result in dental or oral pain, infection, loss of teeth, or other increased oral or dental morbidity.
Patient has physical, intellectual, or medical conditions AND dental treatment under local anesthesia is expected to be unsuccessful. For example: intellectual disability, cerebral palsy, epilepsy, and hyperactivity. (verified by appropriate medical documentation).
Patient has six (6) or more teeth requiring extraction in various quadrants.
Patient has dental treatment needs for which local anesthesia is ineffective because of acute infection, anatomic variation, or allergy.
Other Circumstances (please describe in detail):
EVALUATE FOR TREATMENT
SSCs
SSCs + Pulp
Ext
Fillings
Other
Additional treatment notes
UPLOAD X-RAYS & TREATMENT PLAN
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Patient Authorization to release HIPAA information to MC GAD (Patient Signature)
Authorization to release HIPAA information to Motown Children's (Patient Signature)
Referring Office
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Office Phone
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Doctor Recommending General Anesthesia
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First Name
Last Name
Doctor Signature
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DATE
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Month
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Doctor
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otownchildrens.com
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