Referral for Inhalation Sedation If you are a patient or parent/guardian please click here to refer yourself. Self Referral Title Patient Name * First Name Last Name Date of Birth Sex * Male Female Prefer not to say Parent/Guardian * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * Email * Medical History * Observations and Dental History * Referring Dentist * First Name Last Name Practice Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Practice Phone * Practice Email GDC Number * Referral Criteria * I confirm that the patient being referred is ASA Grade 1 or 2, can breath through their nose and is cooperative enough to follow instructions. Thank you for your referral. We will contact your patient as soon as we are able.Please Note: Orthodontic extractions will not be carried out without a physical or scanned copy of the orthodontists letter.Please send any radiographs or other documents to edward.burton1@nhs.net
