Sedation Referral Form

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2 Blackstrap Rd, Falmouth, ME 04105 (207) 797-3130

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Sedation Referral Form

Patient Name Date

Referred By Phone Number

Reason for Referral Anxiety / Fear Difficulty getting numb Complex dental needs Severe gag reflex Limited opening Needle phobia Other

Radiographs Please Obtain Patient to bring Emailed to office

Treatment Recommendations

Significant Medical History/Remarks:

Contact Information (207) 797-3130 2 Blackstrap Rd,
Falmouth, ME 04105

Office Hours

Monday8:00 am - 4:30 pm
Tuesday8:00 am - 4:30 pm
Wednesday8:00 am - 4:30 pm
Thursday8:00 am - 4:30 pm

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