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ABOUT
OUR SERVICES
DENTIST REFERRALS
CONTACT
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Referral for dental treatment under conscious sedation:
Referrer details:
Dentist name:
*
Practice name
*
Practice address
*
Tel contact number
*
Email
*
Patient details:
Full name
*
Patient Date of Birth
*
Day
Month
Year
Patient Address
*
Patient Phone
*
Patient Email
*
Clinical details:
Full Medical History
*
History of tooth/ teeth requiring treatment
*
Is the patient symptomatic?
*
YES
NO
Radiograph* if needed.
Upload Files
Can add up to 30 files.
Has the patient previously had conscious sedation?
*
YES
NO
If yes, did they experience any complications?
Anything else you would like our Sedationist to be aware of?
*
Submit
ABOUT
OUR SERVICES
DENTIST REFERRALS
CONTACT
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