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
Oral Surgery
Other
MEDICAL NECESSITY FOR ANESTHESIA (REQUIRED)
*
Patient has documentation of failed in-office sedation (e.g. nitrous oxide)
Patient is 2-9 years old requires extensive procedures that cannot be completed in-office
Patient is combative or has behavioral issues that preclude use of local/nitrous for completion of treatment
Patient has a developmental disability/medical condition that prevents in-office treatment (cerebral palsy, epilepsy, developmental disability, Autism, ADHD)
Patient has impacted wisdom teeth
Other circumstances (please describe in detail):
EVALUATE FOR TREATMENT
SSCs
SSCs + Pulp
Ext
Fillings
RCT (apex must be closed)
Additional treatment notes
UPLOAD X-RAYS & TREATMENT PLAN
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X-rays Uploaded
Yes
No
Treatment Plan Uploaded
Yes
Unable to perform examination or x-rays due to: (please describe behavior that made the exam impossible):
Patient Authorization to release HIPAA information to NCGAD (Patient Signature)
Authorization to release HIPAA information to NOVA Children's (Patient Signature)
REFERRING OFFICE
*
OFFICE PHONE
*
Doctor Recommending General Anesthesia
First Name
Last Name
Doctor Signature
*
DATE
/
Month
/
Day
Year
Date
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