• 1Select Procedure and Date

    • 2Select Duration

    • 3Payment

    • 4Patient Info

    • 5Medical History

    • 6Confirmation

    Medical History

    YesNo

    MaleFemale



    Does your child take any medications?*

    YesNo

    Does anyone smoke in your child’s home?*

    YesNo

     

    Allergies*

    YesNo

    Recent cold, cough or reactive airway*

    YesNo

    Snoring, asthma or breathing problems*

    YesNo

    Heart trouble, murmur, or heart surgery*

    YesNo

    Surgery or hospitalizations*

    YesNo

    Problems or complications with anesthesia*

    YesNo

    Cerebral palsy, Epilepsy, Seizures or Fainting*

    YesNo

    Developmental delay, Autism or ADHD*

    YesNo

    Any other medical conditions?*

    YesNo

    I have received the IV Sedation Information papers.*

    YesNo

     

    How many minutes is your drive from home to the dental office?*

     

    Please continue onto the next screen for signing.


    If you have any questions, please contact our billing office:

    Email: billing@pediatricsedation.com

    P.O. Box 2080

    Palm Harbor, FL 34682-2080

    Phone: 813-545-9924

    Fax: 866-773-3520

    Pediatric Anesthesia for Pediatric Dentistry