• Torrington Dental Practice Sedation Referral Form

    Torrington Dental Practice Sedation Referral Form

    Please complete this form for sedation referrals only

  • IMPORTANT INFORMATION

    ANY SUBMISSIONS WITHOUT ALL THREE SECTIONS BEING SUBMITTED TOGETHER WILL BE REJECTED

  • Referral Information

  • Referral date
     - -

  • Patient Information

  • Gender*
  • Date of birth*
     - -
  • Are you happy to be contacted via telephone or email (or both). Please tick to confirm which.

  • Sedation details

  • Dental service*
  • Which type of sedation is required?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Rows
  • SEDATION TEAM

    SEDATION TEAM

    CONFIDENTIAL MEDICAL HISTORY

  • Please complete this section so that we can provide you with safe and comfortable
    treatment.

    It is important to include all information requested. If you withhold
    information, you may put yourself at unnecessary risk.


    Please use the additional space after each question to provide any more details.

  • PERSONAL INFORMATION

    TO BE COMPLETED BY THE PATIENT

  • DENTAL AND MEDICAL HISTORY

  • How would you rate your general health?*
  • Have there been any recent changes in your health?*

  • MEDICATIONS

  • SEDATION HISTORY

  • Have you ever had sedation for any procedure?*
  • If yes, please tick which types:
  • Have you ever had a general anaesthetic?*

  • HEART

    Have you ever had any of the following:
  • Heart attack*
  • High blood pressure*
  • Chest pains/palpitations*
  • Angina*
  • Stroke*
  • Rheumatic fever*
  • Pacemaker/heart surgery*
  • Heart murmur*

  • BLOOD

    Have you ever had any of the following:
  • Anaemia*
  • Sickle cell disease*
  • Excessive bleeding/bruising after treatment or surgery*
  • Blood refused by the transfusion service*
  • Abnormal blood test results*

  • CHEST

    Have you ever had any of the following:
  • Shortness of breath walking*
  • Shortness of breath lying down*
  • Bronchitis*
  • TB*
  • Asthma*
  • COPD/emphysema*
  • Cold/chest infection currently*
  • Cough regularly*

  • OTHER

    Have you ever had any of the following:
  • Fainting/dizziness/blackouts*
  • Liver disease/jaundice*
  • Hepatitis*
  • Kidney disease*
  • Infectious disease e.g. HIV/CJD*
  • Gastric ulcer/hiatus hernia*
  • Diabetes*
  • Thyroid problems*
  • Arthritis*
  • Myasthenia gravis*

  • ALLERGIES

  • Do you have any allergies?*
  • Do you have asthma/eczema?*

  • SOCIAL HISTORY

  • Do you smoke?*
  • If yes, are you interested in giving up?
  • Do you take recreational drugs?*
  • Are you pregnant?*
  • Do you have children under 16?*
  • Do you care for anyone?*
  • Do you have sleep apnoea?*
  • Have you had eye surgery?*
  • Do you have any mental health problems?*

  • Please complete the following questionnaire:

  • If you went to your dentist for TREATMENT TOMORROW how would you feel?*
  • If you were sitting in the WAITING ROOM (waiting for treatment) how would you feel?*
  • If you were about to have a TOOTH DRILLED, how would you feel?*
  • If you were about to have your teeth SCALED AND POLISHED, how would youfeel?*
  • If you were about to have a LOCAL ANAESTHETIC INJECTION in your gum, how would you feel?*
  • Date
     - -
  • DECLARATION FORM

    DECLARATION FORM

  • Declaration by dentist

    I can confirm that I discussed all treatment management options with the patient, including local anaesthetic only, inhalation, sedation, intravenous sedation and general anaesthetic.

    The patient is aware of the differences and has requested treatment with conscious sedation.

  • Date*
     / /

  • Declaration by patient

    I agree that the dentist has discussed the difference between conscious sedation and general anaesthetic, and I have requested treatment with conscious sedation.

  • Date*
     / /

  • As a referral service, we reserve the right to return incomplete or inappropriate referral forms. 

    Referrers are advised that all referrals are subject to audit with respect to their quality and appropriateness.

  •  
  • Should be Empty: