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Pediatric 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.

Please provide contact phone numbers and convenient times to call you prior to the scheduled procedure.
Please provide a secondary contact phone number and convenient time to call you prior to the scheduled procedure.
SmileMD will be emailing you additional information for your child's procedure day and confirmation for the appointment.


Street, City, State, Zip Code
N/A for Self Pay
Briefly list amount of extractions, crowns, pulpotomy, or needing x-rays
The recorded weight must be current, no greater than one month old
Before 34 weeks, if yes please explain below.
Gestational age at birth and how many weeks spent hospitalized prior to discharge?
If yes explain below. i.e. Herbs, OTC Medications
Bring Inhaler Day of Procedure
i.e. insulin pump, pacer etc
If any please explain below.
Please list last date of symptoms
If yes explain below.
Please be as detailed as possible
i.e. Pulmonologist, Cardiologist, etc


Check all that apply.
If none apply, select the no known medical history
Includes: Asthma, Diabetes, Chronic Infections
Please provide the name and number of the individual to accompany you home following the procedure.

SmileMD Pre-Opt Instructions

Your child will be having surgery with general anesthesia. You will need to follow the same pre op guidelines as you would for a hospital surgery.

Do Not or Eat Drink after midnight the night before your appointment. This is very important for the safety during general anesthesia.

A responsible adult (18 years or older) must drive you to and from the appointment. The parent/legal guardian must attend and stay in the office during the procedure. If there is a concern with this, please inform your dental office staff. Be prepared to spend up to 4 hours at the appointment from the moment you arrive to the moment you leave. Parents are required to stay with the child all day before and after the surgery. It is very important to keep an eye on the child to be sure they have nothing to eat or drink.

If your child has asthma you must bring an inhaler to the appointment. Failure to do so may result in same day cancellation.

Inform your dental practice or SmileMD if your child has a cough, cold, or fever.

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.

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.


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. .

Pain can be normal from any Dental procedure, take any medications your medical/dental provider prescribed you.

By signing this I have read and understand the Pre/Post Operative Instructions. By completing this form I agree that all information included is accurate to the best of my knowledge, I certify that I am the legal guardian for the patient and have decision making authority to consent for treatment and services from Offor Health, Inc. As the consenting legal guardian, I agree to have a State approved car seat that is appropriate for the age and weight of my child upon SmileMD discharge. I also agree that I am responsible for all payment obligations arising out of the treatment and services provided by OFFOR Health, Inc., and will guarantee payment for these services.

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


SmileMD Inc.

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