Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Physician Release for I.V. Sedation
Document related concepts
Transcript
Release for Intravenous Sedation Patient’s Name_____________________________Date of Birth____________ Procedure(s) Being Performed______________________________________ ________________________________________________________________ Health Concerns Regarding Patient__________________________________ ________________________________________________________________ Dentist’s Comments_______________________________________________ ________________________________________________________________ Does Patient Require Physician Release for Anesthesia & Dental Surgery?____Yes ____No Dentist’s Signature_______________________________Date_____________ Physician’s Comments Instructions Regarding Medications Patient is Taking___________________ ________________________________________________________________ Physician’s Comments_____________________________________________ ________________________________________________________________ I Release______________________________for Intravenous Anesthesia and (Patient’s Name) Dental Surgery to be Performed. I Do Not Release___________________________for Intravenous Anesthesia and Dental Surgery to be Performed at this time. Physician’s Signature_______________________________Date___________
