IV Sedation Referral

01903 491888

Thank you for choosing to refer your patient to our practice for IV Sedation. We work closely with referring dentists to ensure patients receive safe, comfortable, and well-coordinated care. Please complete the referral form below with all relevant clinical details so that our team can assess the patient’s suitability for sedation and arrange an appointment promptly.

Image of injection in hand for IV sedation

IV Sedation Referral Form

Please complete the form below to refer patients.

*Indicates required field

Patient details

Address

Postcode

Date of birth

Contact number

Email

Reason for referral/treatment required

Medical and Clinical Information

Reason for referral / treatment required
Full medical history including:
- Current medications
- Allergies
- Medical conditions (e.g., respiratory, cardiovascular, neurological)
- History of adverse reactions to sedation or anaesthesia
Dental history relevant to treatment
Current oral health status
Radiographs or photographs (upload if applicable)

Enter details

Anxiety level / behavioural considerations

Special needs or accessibility requirements

Radiographs included Radiographs included Yes No

New Field New Field Bite Wings OPG CBCT

File name to include referring dentist name, patients initials and patient DOB File InputNo Files ChosenAccepted file types: jpg, jpeg, jpe, gif, png. Max. file size: 1 MB

Referring dentists details I have explained the need for referral and obtained my patient's consent for the treatment to be carried out.

GDC Reg No.

Practice name

Practice address

Postcode

Practice Email

Practice contact number

Additional comments

Practitioner Authorisation and Responsibility Statement

I confirm that:

The patient has been clinically assessed by me and requires treatment under sedation.
All relevant medical and dental information provided is accurate to the best of my knowledge.
I have advised the patient of the referral and the nature of sedation treatment.

By submitting this referral, the referring dentist acknowledges that:

The sedation team will independently assess the patient’s suitability for sedation based on medical history, risk factors, and clinical guidelines.

Acceptance for sedation is not guaranteed and will depend on the outcome of pre-assessment.

The referring dentist remains responsible for the patient’s general dental care, diagnosis of underlying dental issues, and ongoing treatment needs outside the scope of the sedation visit.

The receiving practice is not liable for incomplete, inaccurate, or omitted information provided at the time of referral.