Full Name *

Email *

Date *

Phone

Introducing:

Referring Doctor

Patient Phone:

Treatment options - Comprehensive Sedation Dentistry For:

Perio

Fillings

Root Canal

Extraction

Crown

Comprehensive TX

Implant & Crown

Implant only

Tooth #

This patient is being referred for sedation dentistry due to the following symptoms:

Dental Anxiety

Fear of Needles

Difficulty Attaining Numbness

Complex Dental Needs

Strong Gag Reflex

Highly Sensitive Teeth

Previous Negative Dental Experience

Needs Lengthy Appointment

Other

Comments

Please list any remarkable medical conditions below:

I have sent radiographs for your evaluation:

FMX

PANO

BWS

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