Referral for Dental Treatment Under General Anesthesia
Patient Name
*
First Name
Last Name
Patient's Date of Birth
*
Patient Phone
*
Format: (000) 000-0000.
Patient Alternate Phone
Format: (000) 000-0000.
Patient's Dental Insurance
Dental Insurance Subscriber #
Primary Language
English
Spanish
Other
Type of work
Pediatric
Special Needs
Other
MEDICAL NECESSITY FOR ANESTHESIA (REQUIRED)
*
Unable to safely complete treatment in the dental office due to age, behavior, severe anxiety/fearfulness, emotional maturity, or inability to cooperate/communicate.
Developmental disability, cognitive impairment, behavioral condition, or medical condition prevents safe/effective treatment in a traditional dental office setting.
Extensive dental treatment cannot be safely or effectively completed with local anesthesia or minimal/moderate sedation.
Previous in-office treatment, behavior guidance, nitrous oxide, orsedation attempt was unsuccessful.
Medical condition requires treatment in a hospital or ambulatory surgery center setting.
Impacted third molars or other surgical procedure requiring general anesthesia.
Other (please include a description in the narrative below)
EVALUATE FOR TREATMENT
SSCs
SSCs + Pulp
Ext
Fillings
RCT (apex must be closed)
UPLOAD X-RAYS & TREATMENT PLAN
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X-rays Uploaded
Yes
Unable to obtain (please include brief narrative)
Treatment Plan Uploaded
Yes
Unable to obtain (please include brief narrative)
Narrative (include relevant behavior/cooperation level, previous treatment or sedation attempts, medical/developmental conditions (if applicable), extent of treatment needed, and why treatment cannot be safely completed in the dental office.)
*
Patient Authorization to release HIPAA information to SLCGAD (Patient Signature)
Authorization to release HIPAA information to St. Louis Children's (Patient Signature)
REFERRING OFFICE
*
OFFICE PHONE
*
Format: (000) 000-0000.
Doctor Recommending General Anesthesia
First Name
Last Name
Doctor Signature
*
DATE
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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