Pediatric Sedation

Signed Online Scheduling Form

Signed Online Scheduling Form


Patient Info

Patient Name


Patient Nickname






Dentist Name

Dental Procedure Minutes


Demographic Info

Parent Name

Email Address






Cell Phone

Work Phone

Home Phone

I prefer to be contacted by: 


Estimated Dental
Procedure Minutes
Total Prepaid Fee Deposit due at scheduling Balance due prior to procedure
5 $475 $250 $225
20 $700 $250 $450
40 $900 $250 $650
60 $1100 $250 $850
80 $1400 $250 $1150
100 $1600 $250 $1350
120 $1850 $250 $1600
140 $2150 $250 $1900
160 $2450 $250 $2200
180 $2650 $250 $2400
200 $2950 $250 $2700
220 $3150 $250 $2900
240 $3450 $250 $3200


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 us a 24 hour notice.
  • The card on file will be charged automatically for the balance 3 business days prior to the procedure date.
  • On the day of the patient’s procedure, 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.
  • 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 authorize PDAA to send me text messages via SMS texting regarding my child's anesthesia appointment and finances. I understand standard text message and data rates may apply.
  • 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.

October 2, 2023



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Signature Certificate
Document name: Signed Online Scheduling Form
lock iconUnique Document ID: ed4ea6bbc3344c098b470bc885ec9f4eb608bb41
Timestamp Audit
July 22, 2021 4:47 pm EDTSigned Online Scheduling Form Uploaded by Pediatric Dental Anesthesia Associates - IP