Eugene Dental Group Sedation Referral

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Complete this form for your patient's sedation needs. We will reach out to them to schedule a consultation and any necessary films. Please email their most current films and treatment plan to us, as well as an updated medical history, and any medications to office@eugenedentalgroup.com

Email *

Are you referring the patient for: *

Only the treatment needing to be done under sedation

Transferring to our office for continued comprehensive care

Other - please describe more:

If you checked "other", please describe how you want us to see this patient below:

Please describe why you are referring this patient to our office. Please also list any methods you've tried for anxiolysis. Please include the the specific treatment plan of the patient and what you have attempted to do for this patient so far. *

Patient Name *

Patient DOB *

YYYY

Patient Phone *

Patient Email address

Patient Responsible Party *

Insured *

Yes (If yes please include Insurance information below)

Required

Insurance Information if applicable

(Insurance company, Insurance phone, Subscriber Name, Subscriber DOB, ID #, Group #)

Type of sedation requested *

Nitrous Oxide

Oral Sedation

Oral Sedation + Nitrous Oxide

Moderate Conscious IV Sedation

Unsure

Required

A copy of your responses will be emailed to the address you provided.

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