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Michael D. Vaughan, D.D.S.
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330 Wallace Rd. #106, Nashville, TN 37211
(615) 915-6090
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Dentistry for Special Needs
Sedation Dentistry
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New Patient
Dental Clearance Sedation Form
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Patient name
*
This field is required.
Patient date of birth
*
This field is required.
Date of last physical exam
*
This field is required.
Medical history
Seizures
Hypertension
Cardiac Murmurs
Cardiac Anomalies
Asthma
Airway / Trachea Anomaly
Hepatitis
Anemia
Autism
Diabetes Type I
Diabetes Type II
Thyroid Problems
Liver Disease
Kidney Disease
Acid Reflux
Hemophilia
Bleeding Disorders
Cleft Lip/Palate
Cerebral Palsy
Intellectual Disability
ADD/ADHD
Other medical history and/or comments
List current medications
List all allergies and reactions (including medications, foods, and latex)
Any major surgeries/treatments the dentist should know about?<br>Examples: cancer treatment, organ transplant, joint replacement
HEENT (head, eyes, ears, nose and throat)
*
Select an option
WNL (within normal limits)
Not WNL
This field is required.
Cardiac
*
Select an option
WNL (within normal limits)
Not WNL
This field is required.
Lungs
*
Select an option
WNL (within normal limits)
Not WNL
This field is required.
Abdomen
*
Select an option
WNL (within normal limits)
Not WNL
This field is required.
Extremities
*
Select an option
WNL (within normal limits)
Not WNL
This field is required.
Neuro/Psych
*
Select an option
WNL (within normal limits)
Not WNL
This field is required.
Please explain any "Not" WNL (IMPORTANT)
ASA Classification
*
ASA I
ASA II
ASA III
ASA IV
This field is required.
Height
*
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Weight
*
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BP
*
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HR
*
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SaO2
*
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Temp
*
This field is required.
Is antibiotic prophylaxis recommended?
*
Yes
No
This field is required.
Is the patient cleared for IV sedation in the dental office setting?
*
Cleared
Not cleared
Needs further clearance by different provider
This field is required.
If not cleared or needs further clearance, please comment
I attest that I am the Physician or I am authorized by the Physician to complete this form
*
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Print Physician / Authorized Provider name
*
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Date
*
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