Treatment under conscious IV sedation on referral

Please note our sedation sessions are planned, usually weekly. However, there maybe a short wait for treatment.

This process requires patients to attend at least two appointments:

1. Clinician refers patient (No Charge)

Upon reciept of referal Eilertsen Dental Care will contact the patient and arrange a consultation.

2. Treatment Planning Consultation is booked (£53)

The patient will attened the practice to meet with the multidisciplinary team. The clinicians who will complete the work and the sedationist will be present to discuss any questions the patient may have. The work which has been referred will be confirmed with the patient along with the cost of the work. The sedation process will be described and the consent and information paperwork provided.

3. Sedation session booked (Sedation: £250 per session, Treatment: Price provided at planning) Single session is maximum 2hrs. As much work as is needed will be carried out within the timeframe of that appointment. If multiple sessions are required this will have been discussed with the patient.

4. The team will return the patient to your care and will write to confirm the work completed.

For any quieries regarding this process or service agreements the practice manager can be reached on a.turner@eilertsen-dental.co.uk

Patient's Name:

First NameLast Name

Patient's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient's Phone Number: *

Area CodePhone Number

Patient's Email:

example@example.com

Patient's Date of Birth: *

Date

Treatment Required:*

Short description of referral justification and treatment request: *

Description of patient's medical history: *

Conscious IV sedation can only be provided in adult (16years +) patients who are ASA I or ASA II

Patient ASA Score:

III

Has this patient had conscious IV sedation before?*

YesNo

Is the work to be carried out suitable for a dental therapist?*

YesNo

Referring Clinician: *

First NameLast Name

Referring Clinicians Phone Number: *

Area CodePhone Number

Referring Clinician's Email:

example@example.com

Referring Clinician's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Pregnancy (contraindication to receiving conscious sedation for elective treatment)*

I can confirm this patient is not pregnantThis patient is pregnant but wishes to have a consultation for future treatment planning

I have discussed the cost of this referral:*

Required TPC (£53)Sedation excludes treatment (£250, variable)Treatment requested (£ price quoted at the planning appointment)

Upload relevant radiographs: *

Upload recent medical history: *

Signature:*

Treatment Referral