Self referral for Inhalation Sedation Title Patient Name * First Name Last Name Date of Birth Sex * Male Female Prefer not to say Parent/Guardian (Leave blank if you are the patient) First Name Last Name Phone * Email * Addition Infomation Anything you would like addressed, treatment you may need or any concerns you may have. Dentist Information Name and Address of your dentist I am not registered with a dentist Thank you for your interest, we will be in touch as soon as possible. If it is an emergency please contact the practice directly. If you or the patient you are enquiring about have a swelling affecting breathing or swallowing please access emergency care immediately by calling 999 or going directly to A&E
