Contact Us! General Anesthesia (GA) Dental Referral Form

Referring Clinic Name *

Referring Dentist Name *

Clinic Address

Phone *

Fax (optional)

Email *

Referring Coordinator Name (optional)

Patient First & Last Name *

Phone (Mobile) *

Phone (Home) (optional)

Patient Email *

Consent to receive text/email appointment reminders? *

YesNo

Guardian Name

Relationship to Patient

Guardian Phone

Guardian Email (optional)

Reason for GA Referral * (check all that apply)

Severe dental anxiety/phobiaExtensive treatment needsSpecial healthcare needs / limited cooperationFailed treatment attempts with LA/sedation

Medical indication (if applicable)

Other reason (if applicable)

Urgency Level *

Routine (4–12 weeks)Semi-urgent (2–4 weeks)Urgent (pain/infection/swelling)

Current Symptoms (check all that apply)

PainSwellingFeverDrainageTraumaOther

Antibiotics Prescribed?

YesNo

If yes — Antibiotic name, dose & start date

Analgesics Prescribed?

YesNo

If yes — Analgesic name & dose

Chief Dental Concern / Diagnosis *

Radiographs Available? *

Yes - Uploaded BelowYes — will send separatelyNo

Treatment Requested Under GA * (check all that apply)

Comprehensive exam + radiographs (if needed)RestorationsExtractionsEndodonticsStainless steel crownsSpace maintainersScaling/debridementOther

Other treatment details (if applicable)

Preferred Approach (optional)

Definitive treatment in 1 visit where possibleCall referring office before changes to plan

Antibiotic Prophylaxis Required?

YesNoUnknown

Special Notes

Level of Cooperation *

CooperativeLimitedUnable to tolerate care awake

Triggers / Sensory Concerns (optional)

Mobility / Accessibility Needs (optional)

Communication Considerations (optional)

Radiographs (PA / BWX / Pano / CBCT)

Referral Letter / Clinical Notes

Medical Clearance Letter (if available)

Photos (if relevant)

Referring Clinic Confirms * (all boxes must be checked)

Information provided is accurate to the best of our knowledgePatient/guardian has been informed of this GA referralPatient understands there may be a consultation/assessment prior to booking GA

Permission to request records from physician/specialist as needed *

YesNo

Date of Referral *

Referring Dentist Signature / Typed Name *