Dental Sedation Referral Form
Patient Name / NHS NumberAddress
Post Code / GP Name
GP Practice
Post Code
Date of Birth
Contact Number
Sex Male D Female D
PREVIOUS DENTAL EXPERIENCE / SEDATION
Has the patient had dental treatment before? Yes 0 No 0
How has this been carried out? LA 0
Oral Sedation 0
Inhalation Sedation 0
Intravenous Sedation 0
GA 0
Has the patient been refused treatment at any other Sedation clinic? Yes 0 No 0 If yes, give details
RELEVANT RADIOGRAPHS ENCLOSED YES/NO (please tick type)
OPG / Bitewings / Periapical view / Other
TREATMENT REQUIRED
Restorative / Extractions
Other treatment & additional information (e.g. is the patient in pain?, what causes the patient anxiety –needles?)
Medical History
Bleeding disorders Heart Disease Hypertension
Diabetes History of previous/current Lung/Respiratory problems intravenous drug abuse
Liver disease Kidney disease Pregnancy
Breastfeeding Psychiatric/Psychological
problems Cerebrovascular disease
Anaemia
Current medication – please list below
Allergies (please specify)…………………………………………………………………………………………………. Other:
REFERRING DENTAL PRACTITIONER
Name
(please print)
Practice Stamp Practice Telephone number
------Practice Fax Number
------Practice email address
------
Referring dentist’s signature Date
Dental Practitioner Declaration
• I have discussed all alternative methods of providing treatment with the patient i.e. local anaesthetic, oral sedation, inhalation sedation and intravenous sedation and the associated risks of each method as defined in the GDC guidance, and explained each procedure.
• I have taken relevant radiographs which I enclose and I understand these will be returned to me after the patient has been treated.
• Where appropriate I have attempted treatment for this patient in my practice. The treatment was attempted on ………………………. and included:
This did not work for this patient because:
I understand the patient will be referred back to me for any outstanding treatment and recall appointments following their visit. I understand that the sedation clinic may deem the patient suitable for treatment without sedation as the benefit of treatment without sedation outweighs the need for treatment using a sedation technique.
Signature of referring dentist _ _
Name of referring dentist
(Please print)
Date
Please note – Incomplete forms will be refused and returned
Patient Declaration
My dentist has attempted treatment where possible and has explained ‘conscious sedation to me along with the associated risks. My dentist has also discussed the alternative methods of carrying out my treatment.
I understand I should be accompanied only by an adult and that children should not attend unless they are being treated.
Patient’s signature _ (or parent if patient under 16)
Date
Completion of this form is optional, however your help with this survey would be much appreciated. Please hand the completed form to your dentist.
As a requirement under the Equality and Diversity Act NHS England is required to ensure services are equitable and fairfor everyone. It is necessary for the information to be placed on this form but optional for patients to complete.
Ethnic Origin
Religion
Sexual Orientation
Your views regarding any special requirements you may have e.g. wheelchair use, translation services
CAN YOU TELL US HOW ANXIOUS YOU GET, IF AT ALL, WITH YOUR DENTAL VISIT? PLEASE INDICATE BY INSERTING ‘X’ IN THE APPROPRIATE BOX
1. If I you were attending the Dentist for TREATMENT TOMORROW, how would you feel?
Not
Anxious 0
Slightly
Anxious 0
Fairly
Anxious 0
Very
Anxious 0
Extremely
Anxious 0
2. If you were sitting in the WAITING ROOM (waiting for treatment), how would you feel?
Not
Anxious 0
Slightly
Anxious 0
Fairly
Anxious 0
Very
Anxious 0
Extremely
Anxious 0
3. If you were about to have a TOOTH DRILLED, how would you feel?
Not
Anxious 0
Slightly
Anxious 0
Fairly
Anxious 0
Very
Anxious 0
Extremely
Anxious 0
4. If you were about to have your TEETH SCALED AND POLISHED, how would you feel?
Not
Anxious 0
Slightly
Anxious 0
Fairly
Anxious 0
Very
Anxious 0
Extremely
Anxious 0
5. If you were about to have a LOCAL ANAESTHETIC INJECTION in your gum, above an upper back tooth, how would you feel?
Not
Anxious 0
Slightly
Anxious 0
Fairly
Anxious 0
Very
Anxious 0
Extremely
Anxious 0
Instructions for scoring (remove this section below before copying for use with patients)
The Modified Dental Anxiety Scale. Each item scored as follows:
Not anxious / = / 1Slightly anxious / = / 2
Fairly anxious / = / 3
Very anxious / = / 4
Extremely anxious / = / 5
Total score is a sum of all five items, range 5 to 25: Cut off is 19 or above which indicates a highly dentally anxious patient, possibly dentally phobic