Pediatric Sedation

Online Scheduling

Dental Office

Procedure Date

Patient Last Name

Patient First Name

Patient DOB


Parent Name





Primary Phone

Secondary Phone

Email address

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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 us a 24 hour notice.
  • Our financial office can help patients with medical insurance determine their out of network benefits. 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, however, PDAA is committed to fully assisting you with the pursuit of any potential
  • 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.

Date: October 2, 2023

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Document name: Online Scheduling
lock iconUnique Document ID: 63453a43636c835026da792c6601419126e8561b
Timestamp Audit
March 5, 2021 9:30 am EDTOnline Scheduling Uploaded by Pediatric Dental Anesthesia Associates - IP