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Medical Hx

Dental Office

Procedure Date

Patient Last Name

Patient First Name

Patient DOB

Gender

MaleFemale

Parent Name

Address

City

State

Zip

Primary Phone

Secondary Phone

Email address

I prefer to be contacted by:

TextEmailPhone

Anesthesia Fee Estimate Form

Patient Name:

Estimated Dental Procedure Minutes	Total Prepaid Fee	Deposit due at scheduling	Balance due prior to procedure
5	$450	$250	$200
20	$650	$250	$400
40	$850	$250	$600
60	$1050	$250	$800
80	$1350	$250	$1100
100	$1550	$250	$1300
120	$1800	$250	$1550
140	$2100	$250	$1850
160	$2350	$250	$2100
180	$2600	$250	$2350
200	$2900	$250	$2650
220	$3200	$250	$2950
240	$3500	$250	$3250

Estimated anesthesia minutes given by dentist:

Payment Policy:

$250 Deposit is due at the time of scheduling. There is a $250 charge for patients who fail to keep the IV
Sedation appointment without giving a 24 hour notice.
Our financial office can help patients with medical insurance determine their out of network benefits. On the
date of service you will be given a Superbill to file the anesthesia through your out of network benefits. Many
medical insurance companies do not cover anesthesia services for office based dental care, however, PDAA
is commuted to fully assisting you with the pursuit of any potential reimbursement.
Your dental treatment plan may change after treatment is begun. Charges for anesthesia services may be
more or less than the estimated amount based on the final length of the procedure. The anesthesia charges
may be more than initially estimated and an additional payment by credit card is due at the time of
service. Any overpayments will be refunded automatically to you.
We accept cashier’s check , American Express, Discover, Visa, MasterCard, and Carecredit for payment in
full 3 business days before the patient is treated. You can apply for Carecredit at www.carecredit.com

I understand that my health plan (Tricare and other plans) may impose a limit on balance billing by out of
network providers. I wish to waive any limit on balance billing and receive treatment from this out of network
provider.
I understand that I am seeking the care of PDAA for a service that may not be covered by my insurance
company. I understand that my insurance plan may not cover any part of the charges, costs or expenses
related to Anesthesia services and I will be responsible for all charges incurred.

Parent Name:

Date: April 26, 2024

Medical History -

Gender:

MaleFemale

Age:

Date of Birth:

Parent’s Name:

Child’s height (if known):

Child's weight:

lbs

Home #:

Work #:

Cell #:

Dentist:

Does your child take any medications?

Yes

Does anyone smoke in your child’s home?

Yes

Allergies

Yes

Recent cold, cough or reactive airway

Yes

Snoring, asthma or breathing problems

Yes

Heart trouble, murmur, or heart surgery

Yes

Surgery or hospitalizations

Yes

Problems or complications with anesthesia

Yes

Cerebral palsy, Epilepsy, Seizures or Fainting

Yes

Developmental delay, Autism or ADHD

Yes

Any other medical conditions?

Yes

I have received the IV Sedation Information papers.

YesNo

Today's Date

Parent Name:

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Timestamp

Audit

July 14, 2021 10:11 pm EDT

Medical Hx Uploaded by Pediatric Dental Anesthesia Associates - billing@pediatricsedation.com IP 172.254.226.179