Conscious Sedation Referral Form

Patient Details
ID Reference:
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Referrer Details
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Referrer Contact Details
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Select option (please tick) The sedation costs £200 plus any treatment and will be charged directly to the patient
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Please check you have uploaded a compatible file format and the file doesn't exceed 5MB.
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Please check you have uploaded a compatible file format and the file doesn't exceed 5MB.
File uploaded successfully
Please check you have uploaded a compatible file format and the file doesn't exceed 5MB.
File uploaded successfully
Please complete sections below:

Treatment Requested:

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If yes please state type and quantity

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This field needs to be confirmed
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This field needs to be confirmed

Please note: During treatment the patient will remain in the overall care of the referring dentist for emergency and routine dental care.

This is required in order to submit the patient referral form
Please confirm for security reasons

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Opening Hours

  • Mon to Wed:
    8:30am – 6:00pm
  • Thursday:
    8:30am – 8:00pm
  • Friday:
    8:30am – 5:30pm
  • Saturday & Sunday:
    Closed

Little Common Dental Practice © 2022.
65 Barnhorn Road, Little Common, Bexhill-on-Sea, East Sussex TN39 4QB.