For Dentists — Plumfield Dental

Inhalation Sedation Referral.

We’re proud to accept referrals for treatment under inhalation sedation here at Plumfield Dental.

Any patient referred to the practice for treatment with inhalation sedation would be assessed and treated with courtesy and kindness, before being referred back to you for their continuing care.

A fee of £100 will be applicable for the initial consultation that will be required to secure an appointment; this fee is non-refundable if the appointment is missed or cancelled with less than 24 hours’ notice. Please inform your patient of this before continuing with the referral form.

Patient Name

First Name

Last Name

Patient Date of Birth

YYYY

Patient Address

Patient Contact Number

(###)

###

####

Referrers Name

First Name

Last Name

Referrers Practice Name & Address

Referrers Email

Referrers Contact Number

(###)

###

####

Please give a description of what treatment is to be carried out under inhalation sedation.

Has treatment been attempted pre-referral?

Reason for Referral:

For example, Anxiety, Gagging, Sensitivity, Ortho Extraction etc.

Please detail any relevant medical history

Does the patient have any previous experience with sedation?

Are there any relevant radiographs to accompany the referral?

If yes, please email them to maysa.hattab@nhs.net

Are there any known barriers to mobility?

Are there any known barriers to communication and/or consent?

The patient been informed that an assessment will be required, and the associated fee.

Please use this space to add any other information you think will be useful.

Inhalation Sedation Referral.

Hours:
Monday – Friday
9am – 5:15pm

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Useful Links:
Privacy Statement
Complaints Procedure
Appointment Management Policy
Practice Plan Membership Policy

Company Number: 09764748
Registered Office Address: Self Assessment House, 85-87 Saltersate, Chesterfield, S40 1JS

Inhalation Sedation Referral.

Hours:Monday – Friday9am – 5:15pm

Follow:FacebookInstagram

Useful Links:Privacy StatementComplaints ProcedureAppointment Management PolicyPractice Plan Membership Policy

Company Number: 09764748Registered Office Address: Self Assessment House, 85-87 Saltersate, Chesterfield, S40 1JS

Hours:
Monday – Friday
9am – 5:15pm

Follow:
Facebook
Instagram

Useful Links:
Privacy Statement
Complaints Procedure
Appointment Management Policy
Practice Plan Membership Policy

Company Number: 09764748
Registered Office Address: Self Assessment House, 85-87 Saltersate, Chesterfield, S40 1JS