By filling out this form, our clinical team will determine if you qualify to be scheduled directly for your sedation appointment. This is not a guarantee that you will qualify, and if we find it necessary, we will reach out to schedule you to come in for further evaluation leading up to your sedation appointment. 

Please be thorough in filling out every field of this form. If you have any questions, reach out to the office and we will work to assist you (Batavia at 513-732-0541, Blue Ash at 513-984-3817 and Lebanon at 513-282-6200).


Personal Info and Referral

A number of Medicaid plans now require prior authorization for IV Sedation. As a result, they're wanting to know more specifics about your unique situation. The following questions should be answered fully and honestly as they may be used by the insurance company if you will qualify for extractions and/or IV Sedation. 

Health History

Select the categories below to confirm whether you, as the patient,  have any health history or current issues in the following categories. If you're unsure, select "I'm not sure" and a list of more specific health history issues will guide your answer.