Patient Referral

To be completed by the referring practice. Please have the details below ready before starting.

Patient's Details

Patient's first name

Patient's last name

Patient's address — address line 1

Address line 2 (optional)

City

State

Postal code

Patient's date of birth

Patient's phone

Patient's email

Practice Details

Practice name

Practitioner performing the procedure

Treatment

Proposed treatment (select at least one)

Extractions

Implants

Restorations

Scale & Clean

Periodontal

Impressions

Crown/Bridge

Other

Expected treatment duration (select at least one)

1 hour

1.5 hours

2 hours

>2 hours

Information

Sedation information provided to patient — Completed

Sedation instructions provided to patient — Completed

Sedation pricing discussed with patient — Completed

Sedation written consent obtained — Completed

Online medical history link provided to patient to complete — Completed

Appointment

Appointment 1 — date and time

Appointment 2 (optional)

Appointment 3 (optional)

Appointment times must be between 8:00am and 6:00pm.

Sign-off

Name of person completing this form

Deluxe Dental Sedation — Dr Shabbir Kermali, Dental Sedationist