New Intake – Michael D. Vaughan, D.D.S.

Patient First Name

This field is required.

Patient Last Name

This field is required.

Patient Date of Birth

This field is required.

Has the patient ever needed sedation (IV) or sedation medication in order to complete dental treatment?

Yes

I'm not sure

The patient has never received dental treatment

This field is required.

When was the last time the patient successfully had dental X-rays taken at a dental office?

Within the last 12 months

1-2 years ago

More than 2 years ago

I don't remember

The patient has never been able to complete dental x-rays

This field is required.

Can the patient typically sit in a dental chair and allow a dentist or hygienist to examine their mouth?

Yes, without difficulty

Yes, but with some difficulty or accommodations

Usually not

I'm not sure

This field is required.

Important Information about Sedation

Based on the information provided, the patient may require sedation or additional accommodations for dental treatment.

All new patients who may require sedation must first be seen for a Sedation Consultation.

During this appointment, our clinical team will evaluate the patient, review their medical and dental history, and determine the appropriate level of sedation for future dental treatment.

Dr. Vaughan is a Conscious Sedation dentist and provides sedation services in our dental office.

For patients who require a deeper level of sedation, we work with a mobile anesthesia team that can provide deep sedation or general anesthesia in our office.

All sedation services arranged through our practice are provided in-office only.

Sedation Consultation fee & coverage

The Sedation Consultation fee is $250.00.

If the patient has qualifying ECF Dental coverage or 1915(c) Waiver dental coverage, the Sedation Consultation may be covered, subject to eligibility and benefit verification.

Please note: Having ECF medical coverage does not necessarily mean the patient has ECF Dental coverage.

If the patient does not have qualifying dental coverage, the $250.00 Sedation Consultation fee must be paid before the appointment can be scheduled.

The $250.00 fee is for the Sedation Consultation only and does not apply toward any future dental treatment.

Sedation Clearance required before scheduling

Before we can schedule a Sedation Consultation, we must receive a completed Sedation Clearance from the patient's Primary Care Provider (PCP) or appropriate medical specialist.

We cannot schedule the Sedation Consultation until the required medical clearance has been received and reviewed by our office.

After you submit this New Patient Intake, we will provide instructions for completing the Sedation Clearance process.

I understand that a Sedation Clearance from the patient's PCP or appropriate specialist must be received and reviewed before a Sedation Consultation can be scheduled.

This field is required.

I understand that if the Sedation Consultation is not covered by qualifying ECF Dental or 1915(c) Waiver dental coverage, the $250 consultation fee must be paid before scheduling and does not apply toward future treatment.

This field is required.

New Patient Intake

Welcome to Michael D. Vaughan, DDS

Important Information about Sedation

Sedation Consultation fee & coverage

Sedation Clearance required before scheduling

Expert Dental Care for Your Needs

Michael D. Vaughan, DDS

Call Today:

Office Location:

Quick Links

Office Hours