Microsoft word - pds-0002e

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It has been recommended your child undergo I.V. Anesthesia in order to render the necessary dental treatment. On the day of the surgery, the anesthesiologist will provide the anesthesia, monitor and manage his/her recovery throughout the visit. A pre-paid deposit of $550.00 to the anesthesiologist is required in order to reserve the appointment time. This deposit will then be applied towards the first hour of anesthesia cost on the day of surgery. If the anesthesia is extended beyond one hour, a fee of $110.00 for each additional 15 minutes will be applied and is due upon completion of treatment. YOUR DEPOSIT WILL BE FORFEITED IF… • An advance notice of 5 business days for cancellation is not given. • You fail to show up for your appointment. • You fail to follow pre-operative instructions concerning eating or drinking. This includes chewing gum. Not only does this pose great risk to your child’s safety during anesthesia, it will also lead to the cancellation of the appointment. Please note: The following treatment plan is based on the visual examination. On the day of surgery, x-rays may be taken if necessary. There may be changes or additions to your child’s treatment plan based on the diagnosis of the x-rays. Preventative procedures such as sealants may also be completed if needed. Should you have any further questions please feel free to contact our office. If you need to contact the doctor after hours, the answering service will assist you. I have read, and fully understand the anesthesia policy and agree to the terms as stated. ____________________________________ _____________________________ _____________ ____________________________ _____________ Santos Cortez, D.D.S., Inc. – Ana M. Planells, D.D.S. – Estela Sanchez, D.D.S. 3320 Los Coyotes Diagonal - Suite 200 - Long Beach, CA 90808 – (562) 377-1375 – Fax (562) 377-1343 INSTRUCTIONS FOR PATIENTS PRIOR TO ANESTHESIA SERVICES The following instructions are so important that deviation from them may result in severe illness or death. For this reason, not following these instructions may require rescheduling the anesthesia services. Parents do NOT accompany the sedated child during dental treatment. EATING AND DRINKING: Nothing by mouth (food or liquid) to be given after midnight unless discussed with the anesthesiologist. This will be the one time we ask you NOT to brush your child’s teeth. This is to prevent accidental swallowing of liquids. MEDICATIONS: Patients should take their normal daily medication unless otherwise instructed by the anesthesiologist. CLOTHING: Wear comfortable (loose) clothing, such as short pants and short-sleeved shirt. Children should bring along an extra change of clothes. Please do not wear jewelry or contact lenses. TRANSPORTATION: A responsible adult must drive the patient home after treatment. It is not acceptable to use public transportation after undergoing anesthesia. Do not drive for 24 hours after treatment. A responsible adult must spend the remainder of the day with the patient. CHANGE IN HEALTH: Please inform the Anesthesiologist of any change in your health as soon as possible. Some illnesses may necessitate delaying your treatment. PAIN: Take pain medication as directed. Management of post-operative dental pain is best accomplished by taking ibuprofen-type medications (Advil, Motrin, etc), if tolerated by the patient. Do not wait for pain to develop. If the patient cannot take this type of medication it is recommended to use acetaminophen (Tylenol), as directed. EATING AND DRINKING AFTER TREATMENT: Start with clear liquids once you are home. Slowly introduce soft, bland food into the diet. If there is some bleeding in the mouth cold liquids are best. Local anesthesia may have been used during treatment so please avoid chewing until the patient is no longer numb. Nausea and/or vomiting are a basis for calling the Anesthesiologist or our office. ELEVATION OF TEMPERATURE IN CHILDREN: Your child may experience an increase in temperature post-operatively. This is usually due the child’s inability to sweat when given one of the anesthetic medications. This is best managed by giving plenty of fluids and/or giving your child Tylenol, Advil or Motrin as recommended on the manufacturers label (if tolerated and not allergic to these medications). If the temperature rises above 101° F, please call the Anesthesiologist or our office. If you have any questions please contact our office at (562) 377-1375. I HAVE READ AND UNDERSTAND THE ABOVE:____________________________ DATE:__________ Santos Cortez, D.D.S., Inc. – Ana M. Planells, D.D.S. – Estela Sanchez, D.D.S. 3320 Los Coyotes Diagonal - Suite 200 - Long Beach, CA 90808 – (562) 377-1375 – Fax (562) 377-1343

Source: http://www.pediatricdentalspecialists.net/docs/PDS-0002E.pdf