Treatment under conscious IV sedation on referral

Type of treatment requested:

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

Short description of referral justification and treatment request:

Description of patient's medical history:

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

INFORMATION REGARDING REFERRING FOR TREATMENT UNDER SEDATION:

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 receipt of referral Eilertsen Dental Care will contact the patient and arrange a consultation.

2. Treatment Planning Consultation is booked (charge according to treatment required and treating clinican fee).

The patient will attend 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: £350 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 treatment coordinator can be reached on shanni.clayton@eilertsen-dental.co.uk

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

Have you discussed conscious IV sedation with your patient?

Patient ASA Score:

Has this patient had conscious IV sedation before?

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

Pregnancy (contraindication to receiving conscious sedation for elective treatment)

I have discussed the cost of this referral:

Upload relevant radiographs:

Upload recent medical history:

Signature:

Referral for Treatment