Download Physician Release for I.V. Sedation

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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___________