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Adult Patient Health Screen

Pre-Operative Health Screen

Please fill out this form so that we may plan your anesthetic accordingly. A member of the SmileMD team will try to contact you prior to the procedure to discuss the anesthetic. If you do not receive a pre-operative call, you will have an opportunity to discuss the anesthetic before your procedure.


If yes please explain below.
If yes explain below
If any please explain below.
If yes explain below.
Please be as detailed as possible


Please provide contact phone numbers and convenient times to call you prior to the scheduled procedure.
Please provide the name and number of the individual to accompany you home following the procedure.

SmileMD Pre-Opt Instructions

Do Not Drive, a responsible adult (18 years or older) must drive you to and from the appointment, the patient is not allowed to drive until the next day, no exceptions. Please provide the front office staff with your driver's name and contact information. It is preferred the driver stays in the office during the procedure. If there is a concern with this, please inform your dental office staff. If your driver is not ready to take you home at the end of your appointment, it could result in extra charges.

Do Not or Eat Drink 8 hours prior to your appointment time.

Do NOT take any drugs or prescription medications that are NOT PRESCRIBED to you 3 days prior to sedation appointment, serious contradictions can occur. IF you have, you must alert the Provider PRIOR to placing the I.V.

Do NOT consume Alcohol 24 hours prior to your appointment.

Do NOT Smoke 24 hours prior to your appointment.

Failure to follow the above instructions could result in rescheduling or denying of treatment. If you have any questions regarding the instructions, please call us right away.

Wear loose, comfortable clothing, avoid jewelry including earrings. You may bring your favorite blanket* or ear buds with a portable music player* for your comfort. *SmileMD is not responsible for your personal belongings at any time.

At the time of the procedure our Provider will reconfirm your health history and last physical with your physician. Our Provider will ask for your signature on a consent form prior to treatment.

Females will be asked to take a pregnancy test or sign a waiver at the time of sedation. If you test positive for pregnancy, sedation cannot be administered.

After all paper work is signed and reviewed, the Provider will place sticker like monitors in the areas of chest (2) and side (1). A finger cuff is then placed on the finger, and a vital base line is achieved. An IV is then started. The Provider will start adding medications through the I.V. As the medication enters, you will start to feel sleepy, you will be able to respond and move as the medication gives a twilight like sleep. You will hear us; however you may not have memory. When the dental/medical procedure ends the Provider will stop delivery of medications and begin recovery. The Provider will stay with you until you are awake. The Provider will then aide in walking you to your vehicle, with your driver, and fasten your seat belt.

PRE-OPERATIVE INSTRUCTIONS: Do not eat or drink anything for eight hours before your procedure unless your anesthesiologist says otherwise. If you take blood pressure or diabetes medicines, please discuss with your anesthesiologist during your pre-operative call or before your procedure. If you take any other medications on a regular basis, you may take those medications the morning of your procedure with a sip of water.


SmileMD Post-Opt Instructions

Your driver should be sure you are in a restful area; i.e. bed, couch. Avoid stairs; the patient must have help going up and down stairs until the full effects of the medication are gone. Use caution going to the restroom, as you might be disoriented, use hand rails when available. You should not be supervising others, especially children, until the effects of the medication wear off. It is advised not to take phone calls or business meetings, as you may not remember what you discuss, a common side effect of the medications used.

A Sedation Specialist will call you later in the evening to see how you are feeling. They will ask questions in regards to your sedation treatment, not your dental treatment. (If you have questions with your dental treatment, please call your dentist right away). Your food intake should be slow and should consist of soft light foods like Jello, crackers and broth. Nausea can be normal for 24 hrs. If no nausea is present, you may slowly intake normal foods. Avoid spicy foods. Be sure to follow your dentist diet recommendations. Bruising around the I.V site may be normal. Itching may be a side effect as well. If you have redness or a rash, please contact us right away. Pain can be normal from any Dental procedure, take any medications your medical/dental provider prescribed you. Avoid ibuprofen for 6 hours after your procedure.

Pain can be normal from any Dental procedure, take any medications your medical/dental provider prescribed you. Avoid ibuprofen for 6 hours after your procedure.

By typing my name, I have read and understand the Pre/Post Operative Instructions.

SmileMD Patient Financial Policy

Office based sedation is not a benefit paid by most health/dental insurance plans and as a result SmileMD does not file claims or accept compensation from any insurance payors. SmileMD is a Patient Paid/Fee for service sedation provider.

SmileMD requires a deposit at time of scheduling. Depending on your case and dental office, the deposit covers the cost of the SmileMD provider pre-case preparations, post-case discharge and either the first (30) OR (60) minutes of sedation. The patient will be notified of their deposit fee, time covered by the deposit, as well as an estimated total fee* for sedation. The patient will be make the deposit using any major credit or debit card over the phone with their SmileMD Scheduling Coordinator via our Secure Payment system. The anesthesia provider WILL NOT be scheduled with the Practice's office until the deposit payment has been received and verified by SmileMD.

For cases exceeding the 30 or 60 minutes (depending on deposit coverage communicated) additional sedation fees, billed in (15) minute increments (per official sedation record start and end/discharge times), shall be invoiced immediately following your case. Final payment of these additional sedation fees shall be automatically charged to the credit card provided for the patient deposit. Acknowledging this financial policy hereby authorizes SmileMD to initiate this charge for Final Payment to the card provided.

Final payment for additional sedation services is due the next business day after the case. If final payment to the card on file is declined or otherwise uncollected within 5 business days, a $100 late fee shall be applied to the Patient's balance due. SmileMD will contact the payment the business day of the decline to allow the Patient to rectify.

If final payment and any applicable late fees has not been received within 60 days, SmileMD reserves the right to initiate Collection procedures. Upon entering "Collection" status, the Patient agrees to pay the Final payment, and any applicable late fees and all Collection costs incurred by SmileMD.

*SmileMD estimates the total case fees based upon the sole opinion of your practitioner. Depending on the complexity of your case and unknown complications, your case may take more or less time than estimated. Actual case times are based solely on the care provided by your dental/medical practitioner. SmileMD does NOT control or accept responsibility for cases exceeding fee estimates.

For the convenience of our Patient we accept Visa, Mastercard, Discover, and American Express Credit/Debit cards. We collect payments via phone through our HIPAA and PCI Compliant Secure Payment Service. SmileMD does not keep or store Patient credit card or payment information at its premises or company servers for your protection.

Cancellation/Re-scheduling: Deposits are refundable with the exception of a $400 fee*** UNLESS a 48 BUSINESS HOUR notice is provided. Notice given prior to 48 BUSINESS HOURS will be given a full refund to the Credit/Debit Card used at the time of deposit payment.

SmileMD Initiated Cancellation/Re-scheduling: SmileMD Providers have the right to refuse or deny sedation treatment based on the health assessment of any Patient***

***SmileMD will not refund the cash deposit due to patient negligence and/or if the Patient failed to disclose health information relevant to the determination of SmileMD to provide/not provide sedation OR the anesthesia professional is unable to perform sedation due to an inability to place an IV due to reasons out of their control.

By typing my name, I have read and agree to adhere to the financial policy requirements, including authorizing SmileMD to charge my card on file for final payment.

Medical Release

I authorize the release of any requested medical records or other health care information, including reports, lab results, and other written information concerning my health and treatment to be sent to the following company.

SmileMD 5890 Venture Dr. Suite A Dublin, OH 43017 Phone: 614-401-4402 Fax: 877-807-9547 info@smilemdsedation.com

By typing my name I agree to SmileMD contacting my healthcare physician for any medical records needed.

Please call our Office if you have any questions or concerns. 614.401.4415


SmileMD Inc.

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