adult IV sedation & treatment Referral form

By submitting this form, you confirm the following:

• Your patient is aware that dental treatment and sedation will be provided by Dr. Shilpa Shah.
• Your patient is aware of and consents to being contacted by one of our clinics to organise their sedation assessment appointment before booking any treatment.
• You have provided a complete and accurate medical history and relevant radiographs.

Failure to accurately complete this form may lead to a delay or rejection of your referral.

Once your referral is submitted, a member of our team will contact the patient to organise an appointment.