Sedation check-in Ready to check-in? Please complete our sedation check-in form below. If you have any questions call us on (615) 348-1008. HiddenVersion historyv2.3 : Removing DOB, Copy to options and change on mobility risk (2022-04-01) v2.2 : Mobility risk question added (2022-01-21) v2.1 : Questions about breastfeeding and pregnancy added (2021-09-29) v2.0 : No COVID-19 Screening and Medical History question added (2021-03-18) v1.6 : Updated CDC Guidelines (10 days quarantine) v1.5 : Thank you confirmation page (add), 2020-06-23 v1.4 : Receive a copy by email (add), 2020-06-05 v1.3 : New header, height as dropdown, vehicle color and no captcha (change), 2020-06-04 v1.2 : DOB changed to date dropdowns (change)Patient name:(* required) First Last Patient sex:(* required) Male Female Height(* required)-4 ft. 0 in.4 ft. 1 in.4 ft. 2 in.4 ft. 3 in.4 ft. 4 in.4 ft. 5 in.4 ft. 6 in.4 ft. 7 in.4 ft. 8 in.4 ft. 9 in.4 ft. 10 in.4 ft. 11 in.4 ft. 12 in.5 ft. 0 in.5 ft. 1 in.5 ft. 2 in.5 ft. 3 in.5 ft. 4 in.5 ft. 5 in.5 ft. 6 in.5 ft. 7 in.5 ft. 8 in.5 ft. 9 in.5 ft. 10 in.5 ft. 11 in.5 ft. 12 in.6 ft. 0 in.6 ft. 1 in.6 ft. 2 in.6 ft. 3 in.6 ft. 4 in.6 ft. 5 in.6 ft. 6 in.6 ft. 7 in.6 ft. 8 in.6 ft. 9 in.6 ft. 10 in.6 ft. 11 in.6 ft. 12 in.7 ft. 0 in.7 ft. 1 in.7 ft. 2 in.Patient weight (lbs):(* required)Please enter a number from 30 to 400. Pre-appointmentWhat time did the patient last eat?(* required) : AM PM AM/PM What time did the patient last have something to drink?(* required) : AM PM AM/PM What time did the patient last take medication?(* required) : AM PM AM/PM Were any scheduled medications held today?(* required) Yes No If you don't know the answer, please contact agency/conservator and ask.If yes, list medications that were held:(* required)Did the patient take a pre-med prior to this appointment?(* required) Yes No If you don't know the answer, please contact agency/conservator and ask.Medication name, dose and time:(* required) Mobility Concerns* Please let us know if the patient needs to be transported in a wheelchair and we will be happy to supply one. Medical historyIs there any chance that patient is pregnant?(* required) Yes No I don't know Is the patient breastfeeding?(* required) Yes No I don't know Has the patient ever had a negative reaction to sedation?(* required) Yes No If you don't know the answer, please contact agency/conservator and ask.If yes, list symptoms:(* required)Has the patient had any recent changes in medications?(* required) Yes No If you don't know the answer, please contact agency/conservator and ask.If yes, list changes:(* required)Has the patient had any recent changes in his/her medical history?(* required) Yes No If you don't know the answer, please contact agency/conservator and ask.If yes, list changes:(* required)Has the patient been hospitalized within past 12 months?(* required) Yes No If you don't know the answer, please contact agency/conservator and ask.If yes, list date and reason for hospitalization:(* required)Does the patient have a history of seizures?(* required) Yes No If you don't know the answer, please contact agency/conservator and ask.If yes, when was the last seizure?(* required) MM slash DD slash YYYY Is the patient diabetic?(* required) Yes No if yes, list blood glucose (mg.dl):at time (last verification): : AM PM AM/PM HbA1C (%):Please enter a number from 0 to 100. Driver/caregiver contact info:Driver name:(* required) Driver phone number:(* required)Relationship to patient:(* required) Vehicle color:(* required)-BlackBlueBrownGold/YellowGrayGreenRedSilverWhiteOtherVehicle color (other):(* required) Vehicle (make and model)(* required) Post sedation instructions Do not leave the patient alone after sedation. Do not allow the patient to sleep for at least 3-4 hours following appointment. Continue to engage patient following sedation, as he/she may be affected by some trace amounts of medication still left in his/her system. If the patient is seated, recline backwards and tilt patient’s head back to keep airway open. If patient is lying down, try to position patient on his/her side. Continue to engage the patient and discourage sleeping right after appointment. Watch for signs of resedation, including disorientation and lack of clear breathing. PATIENTS SHOULD NOT SLUMP FORWARD, as it may cut off the ability to breathe well. Moving sedated patients: Patients should be accompanied by someone following a sedation appointment. Hold the patient as he/she enters and exits the car and house. It may be necessary to get assistance from an additional adult to transfer a patient unable to walk steadily. Eating after sedation appointments: Start by hydrating adequately with fluids such as milk, water, or juice. Introduce solid foods slowly to avoid nausea and vomiting. Only feed if patient is fully awake to avoid risk of choking or aspiration. Patients should not drink grapefruit juice due to interactions with sedation drugs. To the caregiver who brought the patient to the appointment, please read and check to confirm the following:I understand that it is my responsibility to look after the patient for at least 3-4 hours after sedation. If the patient will not be under my care, I will ensure that his/her caregiver is aware of the post-sedation instructions and contact information the Practice should there be any concerns.(* required) I confirm! I understand that I will not feed the patient if she/he appears to be slightly sedated.(* required) I confirm! I understand that I will continue to give the patient all scheduled medications unless otherwise specified by the doctor. If the patient still appears to be sedated after the visit, I will contact the Practice and notify of any missed medications.(* required) I confirm! I will continue to watch the patient for any signs of sedation after leaving the dental office (i.e. sleeping excessively or in a fashion out of the ordinary, snoring, or difficulty breathing while sleeping, or not being arousable upon calling). I understand that if the patient is not doing well or has any actions or behaviors that are strange or out of the ordinary, that I will immediately notify the Practice or the patient’s Primary Care Physician. If unable to reach the Practice or PCP, I will take patient to an urgent care facility.(* required) I confirm! Final instructionsPlease contact the Practice within a few hours after the appointment if the patient does not appear to be behaving normally or to let us know if the level of sedation was difficult to manage after the appointment. If you experience any complications, please call our office at 615-915-6090 during office hours. If you are calling outside of office hours, leave us a voice message and we will return your call as soon as possible. SubmitAny questions?Please sign(* required) Reset signature Signature locked. Reset to sign again Important: You consent to sign this document electronically.