Dental Sedation Referral Form

If you are a dental professional you can use the form below to refer to us for sedation dentistry. We look forward to hearing from you.

Sedation Checklist
* required fields

Please tick to confirm that you have checked the following:


Yes  No


Yes  No


Yes  No

Justification for sedation - please tick all that apply:

Anxiety
Lack of co-operation
Needle phobic
Prolonged / unpleasant treatment
Increased gag reflex
Other (please state)
Practice Details
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Patient Details
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Medical Details
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Attach X-ray (or other relevant) files



 

Simply fill out the form above and we'll contact the patient to arrange a convenient appointment