Sedation Referral

Patient

Please speak to your dentist if you feel you would benefit from an appointment with us. We regret we cannot see you without a referral. This ensures that you are receiving the very best dental care as we do not provide general services.

Dentist

Please fill in the referral contact form below with the required information. Or alternatively please print out the form and post it in to us at 16-17 West Town Road BS48 3HA Backwell, Bristol

Sedation Referral Form PDF

Download

Sedation Online Referral Form

Patient Details

First Name *

Surname *

Date of Birth *

Address *

Post Code *

Patient Number *

PLEASE WRITE THE REASON FOR REFERRAL: Anxiety /Phobia, Gag Reflex, Failed LA, Surgical Procedure Please give details about or any medical information which might affect the provision of treatment: *

Patient’s ASA classification *

BMI ≤ 35 BMI at time of referral *

Patient’s OH status: Satisfactory/Poor *

Relevant diagnostic Grade Acceptable radiographs must be provided (Preferably digital/email) (Tooth notation / surfaces of fillings clearly marked / diagnoses justifying treatment must be included)

Teeth to be conserved

Click or drag a file to this area to upload.

Choose File

Teeth for removal

Click or drag a file to this area to upload.

Choose File

Other Treatment

Click or drag a file to this area to upload.

Choose File

Cosmetic restorative / periodontal therapies / definitive endodontic treatment / implants to be referred to our private practice only.

Please ensure that the patient /parents/ guardian understand a consultation appointment is mandatory to obtain valid consent before sedation/treatment can be prescribed.

Referral Dentists/Practice Details

Dental Practice Name *

Referring Dentist Name *

Referring Dentist Number *

Referring Dentist Email *

Thank you for your message. It has been sent.

There was an error trying to send your message. Please try again later.

Patient is aware this is a private referral*

Please send me information relating to my request*

Sedation Referral

Sedation Referral Form PDF

Sedation Online Referral Form

Patient Details

Referral Dentists/Practice Details

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