Cuyahoga County Board of Developmental Disabilities's Patient Referral Form

Patient Information

First Name *

Last Name *

Address

City

State *

Zip

Phone *

Second Phone

Date of Birth *

Please enter a valid date not more than 99 years ago.

Gender *

Language *

Insurance Info

Referral Information

Select Treatment Type *

Pediatric (Max Age 18)

Oral Surgery (Max Age 65)

Endodontic (Max Age 65)

Special Needs (Max Age 65)

Reason for Referral *

Special healthcare needs

Unable to cooperate in a normal office setting

Extensive restorative work requiring sedation

Failed conscious sedation*

Teeth needing treatment *

Which Teeth *

Please only enter teeth as A-T or 1-32 with commas. Example (1,2,3,A,B,C).

Additional Notes

0/255 characters

Attach Files (Allowed File formats .jpg, .jpeg, .png, .pdf, .dcm, .dic, .dicom) 15MB max size

Addl Reason for Referral *

Use of local anesthesia to control pain failed or was not feasible based on medical needs of patient

Use of conscious sedation, either inhalation or oral, failed or was not feasible based on the medical needs of the patient

Use of effective communicative techniques and the inability for immobilization (Patient may be dangerous to self of staff) failed or was not feasible based on the medical needs of patient

Patient requires extensive dental restorative or surgical treatment that cannot be rendered under local anesthesia or conscious sedation

Patient has acute situational anxiety due to immature cognitive functioning

Patient is uncooperative due to certain physical or mental compromising conditions

Other

Signature *