Sedation Referral Form

Practice Details
Practice Name*
Referring Dentist Name*
Referring Dentist GDC Number*
Practice Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Practice Phone*
Practice Email*
Enter Email Confirm Email
Patient Details
Name*
First Last
Patient Email*
Date of Birth*

Day
Month
Year
Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Patient Phone Number*
Reason for Sedation*
Medical History*
Is patient’s BMI close to 40*
- Yes
- No
Treatment Required*
Radiograph Upload
Drop files here or

Max. file size: 256 MB.

Should you prefer to print out and email a referral please print this form (Sedation Referral Form) and email to coatbridgefamilydentalclinic.sms@nhs.scot

We will contact your patient to arrange an appointment