Dentistry under General Anesthesia
Patient Referral Form
Patient:__________________________________ Date of Referral: ________________
Doctor: __________________________________
Office Phone:__________________
Reason for referral:
________________________________________________________________________
________________________________________________________________________
X-Rays (check) ____ with Patient ____ available upon request ____ unable to take
You can also email the X-Rays to
dmd@surewest.net
Welcome to the office of Dr Alexander H Malick, DMD
You have been referred by your attending dentist for evaluation and dental treatment
under general anesthesia/deep sedation. Here is what you can expect:
1. At your first appointment, you will meet Dr Malick and staff and we will
discuss your specific treatment needs.
2. Dr Malick will have you fill out some forms and a certified Dental Anesthesiologist
will contact you to review your health history by phone or sometimes in person.
3. If we feel you are a good candidate for “safe” outpatient anesthesia, we will coordinate
and schedule your treatment.
4. If you need specialty referrals, in most cases, I will have the specialist in my
office to do your work while you are asleep.
5. All fees will be discussed separately by each provider.
6. Normally, medical insurance does not cover these procedures. Your dental
insurance will usually cover the dental work based on your policy provisions.
7. Your Sedation or General Anesthesia will be provided safely by a certified dental
anesthesiologist using the latest techniques, medications, and monitoring equipment.
8. Upon treatment completion, we will refer you back to your attending dentist.
1899 East Roseville Pkwy, Suite 160, Roseville, Ca 95661
Voice (916) 787-1199 Fax (916) 787-0400
www.drmalick.com