GA Referral Form - Clear View Dental

General Anesthesia Referral Form

Malignant Hyperthermia Screening

This question must be answered before the remainder of the form can be completed.

Does the patient or their family have malignant hyperthermia?

Yes

Unfortunately, we are unable to offer sleep dentistry at this time.

Thank you. You may now complete the rest of the referral form.

Patient Information

First Name

Last Name

Phone Number

Address

Patient Address

City

Referring Office Information

Referring Dentist

Office Phone

Office Name

Office Email

Reason for Referral

Why is General Anesthesia being requested?

Medical Screening

Please keep responses brief. Detailed medical clearance can be obtained later if needed.

Does the patient have any significant medical conditions?

Yes

If yes, please specify

Does the patient take any prescription medications?

Yes

If yes, please list

Any known allergies or previous reaction to anesthesia or sedation?

Yes

If yes, please specify

Are Radiographs / Attachments Available

Additional Notes

I confirm that the information provided is accurate to the best of my knowledge.

Yes

Monday

8:00 - 17:00

Tuesday

8:00 - 17:00

Wednesday

8:00 - 17:00

Thursday

8:00 - 17:00

Friday

8:00 - 13:00

Saturday

Closed

Sunday

Closed

General Anesthesia (GA) Dental Referral Form

General Anesthesia (GA) Dental Referral Form PDF

General Anesthesia (GA) Health History

General Anesthesia Referral Form

Malignant Hyperthermia Screening

This question must be answered before the remainder of the form can be completed.

Patient Information

Referring Office Information

Medical Screening

613 - 392 - 3916

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