Pediatric Sedation

Medical Hx

Dental Office

Procedure Date

Patient Last Name

Patient First Name

Patient DOB


Parent Name





Primary Phone

Secondary Phone

Email address

I prefer to be contacted by: 


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
  • 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
  • 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: October 2, 2023




Medical History -




Date of Birth:


Parent’s Name:

Child’s height (if known):


Child's weight:


Home #:

Work #:

Cell #:


Does your child take any medications?


Does anyone smoke in your child’s home?



Recent cold, cough or reactive airway


Snoring, asthma or breathing problems


Heart trouble, murmur, or heart surgery


Surgery or hospitalizations


Problems or complications with anesthesia


Cerebral palsy, Epilepsy, Seizures or Fainting


Developmental delay, Autism or ADHD


Any other medical conditions?



I have received the IV Sedation Information papers.



Today's Date

Parent Name:

Leave this empty:

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Signature Certificate
Document name: Medical Hx
lock iconUnique Document ID: 0dd602d000ea33bf3ef56a041b5b56acd1924de8
Timestamp Audit
July 14, 2021 10:11 pm EDTMedical Hx Uploaded by Pediatric Dental Anesthesia Associates - IP