Chicago Children's Web Referral

Referral for Dental Treatment Under General Anesthesia
Patient Name

First NameLast Name
Date

MonthDayYear
Date
Patient Phone
Format: (000) 000-0000.
Patient Alternate Phone
Format: (000) 000-0000.
Patient's Dental Insurance
Dental Insurance Subscriber #
Primary Language

Other
Type of Work

Other
MEDICAL NECESSITY FOR ANESTHESIA (REQUIRED)

Other
EVALUATE FOR TREATMENT
UPLOAD X-RAYS & TREATMENT PLAN

Cancelof
X-rays Uploaded
Treatment Plan Uploaded
Narrative (please include details on in office treatment, behavior, x-rays & treatment plan):
Treatment subject to change on the day of surgery with new clinical evaluation and X-rays.
Patient Authorization to release HIPAA information to Chicago Children's (Patient Signature)
REFERRING OFFICE
OFFICE PHONE
Format: (000) 000-0000.
Doctor Recommending General Anesthesia

First NameLast Name
Doctor Signature
DATE

MonthDayYear
Date
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Referral for Dental Treatment Under General Anesthesia