Dentist Referral Form

If you are a dental professional you can use the form below to refer to us for sedation dentistry. We look forward to hearing from you.

Please note, we do NOT provide surgical treatment.

Sedation checklist - Please tick to confirm that you have checked the following:

Please confirm patient is over the age of 18.
Please confirm patients BMI meets requirement.
Please confirm discussion with patient.
Please confirm the patient does not suffer from copd.

Justification for sedation - Please tick all that apply:

Please select atleast one of the above justifications.

Practice Details

Patient Details


Clinical Details


Attach X-ray (Or Other Relevant) Files