"*" indicates required fields HiddenNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.Dental Referral FormPediatric full dental rehabilitation under general anesthesiaAbout the PatientPatient Name* Patient First Name Middle Name Patient Last Name Date of Birth* MM slash DD slash YYYY Parent / Guardian* Email PhoneAbout the ReferrerReferring Office* Referring Physician* Email Address* Phone Number*Fax NumberAdditional InformationReasons for referring your patient for full dental rehabilitation under general anesthesia (check all that apply) Patient has severe early childhood caries and/or multiple dental restorative needs (e.g., resin fillings, crowns, pulpal therapy and extractions) with an increased likelihood of pain and infection developing. Patient is uncooperative, combative, or has a diagnosis of impairment and cannot tolerate in-office treatment safely. Patient is currently in pain or urgent care is required in order to prevent pain, infection, loss of teeth or other increased oral or dental morbidity. X-rays Taken (please upload below, or email to pediatricdental@nyqsc.org) Not possible due to uncooperative behavior Upload X-rays below:Max. file size: 100 MB.Evaluate the Following Teeth with Clinical Signs of Caries (please select all that apply below)Select each tooth below that shows clinical signs of caries. Numbers are permanent teeth, letters are primary (baby) teeth. (add following?) Please refer to the image below, sextants ordered right to left. Click each tooth below that shows clinical signs of caries. Numbers are permanent teeth; letters are primary (baby) teeth. Right Left No teeth selected yet. Clear selection Safely treat checkbox The patient has at least 3 of 6 sextants with signs of caries. Due to the patient's age, extent of treatment needs and/or uncooperative behavior, which is documented in their records, they are incapable of being treated safely using in-office modalities. We are referring this patient to be treated for full dental rehabilitation under general anesthesia with your practice.
