IV Sedation Referral Form
Please fill out the form to refer a patient to us for Dental Treatment under IV Sedation at Claris Dental.
Patient Full Name
*
First Name
Last Name
Patient Date Of Birth
*
-
Day
-
Month
Year
Date
Email
*
example@example.com
Telephone Number
*
Please enter a valid phone number.
Format: (00) 00000000.
Address
*
Street Address
Street Address Line 2
Town
County
Postcode
Referring Dentist Full Name
*
First Name
Last Name
GDC No.
*
Referring Dentist Contact Email
*
example@example.com
Referring Practice Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Practice Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for Sedation
*
Anxiety
Invasive procedure
Co-operation
Other
If other, please specify
*
Treatment requested
*
Patients Medical History (Alternatively, please add the file in the below drop box)
*
Radiographs, Photos or Patient Documentation
*
Browse Files
Drag and drop files here
Choose a file
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Additional Notes
*
Confirmation
*
Patient is over the age of 12 years old
Patient is ASA1 or ASA2
Patient weighs less than 150kg
Patient is aware they are being referred for treatment under conscious sedation NOT general anaesthetic
Patient is aware this is a private referral
If the patient is being referred for orthodontic extractions, a copy of the specialist orthodontists treatment plan and relevant radiographs have been enclosed above
Patient is aware that the anaesthetist fee is £350 per hour in addition to any treatment fees
I have read accept the websites privacy terms and policies
*
Yes
No
https://www.clarisdental.com/privacy-policy
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