Pathways Dental
Sleep | TMD | Sedation Referral Form
Thank you for referring your patient to Pathways Dental. We are pleased to assist with evaluation and treatment of Sleep Related Breathing Disorders, Temporomandibular Joint Disorders, and Moderate/Deep Sedation Dentistry. Our goal is collaborative care and return of patients to your practice for ongoing dental treatment.
Referring Provider Information
Referring Dentist / Physician:
Practice Name:
Phone:
Email:
Address:
Patient Information
Patient Name:
Date of Birth:
Phone:
Email:
Reason for Referral (Check All That Apply)
Sleep Related Breathing Disorders
[ ] Snoring
[ ] Suspected sleep apnea
[ ] Diagnosed obstructive sleep apnea
[ ] CPAP intolerance
[ ] Oral appliance therapy
[ ] Laser snore therapy
Temporomandibular Joint Disorder
[ ] Jaw pain
[ ] Clicking / popping
[ ] Limited opening
[ ] Headaches / facial pain
[ ] Bruxism
[ ] Occlusal concerns
[ ] Postural or balance issues
Sedation Dentistry
[ ] Moderate sedation
[ ] Deep sedation
[ ] Severe dental anxiety
[ ] Extensive dental treatment
[ ] Pediatric sedation
Requested Service
[ ] Consultation
[ ] Diagnosis and treatment
[ ] Sedation-supported treatment
[ ] Co-management
Notes
Attachments Included
[ ] Radiographs
[ ] Sleep study
[ ] Medical report
[ ] Treatment plan
Referring Provider Signature:
Date: