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Download Physician Release for I.V. Sedation
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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___________