You will also find several other important forms. Please review and sign the forms listed and fax or mail them to our office as soon as possible.

Transcription

1 Dear Parent: Your pediatric dentist or surgeon has recommended our anesthesia services for your child s dental or surgical care. Our mission is to provide the highest standard of patient care and safety, in the comfort, convenience and familiar surroundings of the office of your child s dentist or surgeon. Anesthetic medications will allow your child to sleep through the procedure in a safe, controlled, and monitored setting thus allowing your child s dentist or surgeon to provide the highest quality, comprehensive and pain-free treatment. Most children report no memory of receiving their dental/surgical treatment. Sedation and anesthesia can provide several additional advantages for your child, which are discussed on the second page of this packet. You will also find several other important forms. Please review and sign the forms listed and fax or mail them to our office as soon as possible. * Pediatric Medical Questionnaire * Medical Evaluation / Clearance Form [Pediatrician to fill this out] * Preoperative / Postoperative Instructions * Financial Agreement Preparation is a very important part of the successful anesthetic. Several weeks prior to your appointment, our office staff will personally phone you at home. They will review your child s health history, explain the anesthesia plan in careful detail, and answer any questions that you might have concerning your child s anesthesia care. We routinely contact parents when medical questions arise, as well as on the evening prior to the day of treatment. We require a deposit of $795 when your child is scheduled for treatment. Failure to submit a deposit may lead to rescheduling your child to a future date. Because of the extensive time, effort, and coordination necessary to schedule patients, the deposit is non-refundable except for illness or cancellation greater than 72 hours prior to the scheduled appointment. IN ADDITION, you will be asked to take your child to their pediatrician for a pre-treatment evaluation. This pediatrician visit should be scheduled 1-2 days prior to the scheduled date of treatment. Please have the medical evaluation form [see above] completed by the pediatrician and returned by FAX to us on the date of the evaluation. Please bring the original, completed form to the office on the date of the procedure. On the day of treatment: Have your child wear loose, comfortable pants, a short-sleeved shirt (and a sweat shirt in winter) Please place a diaper or pull-up on your child, if appropriate. Bring a warm blanket (everyone gets cold during an anesthetic). Your child must not have any food for 8 hours, nor any clear liquid for 2 hours prior to the appointment Bring all forms that both you and your pediatrician were required to complete. Following an examination and discussion with you, your child will be given an initial sedative while you are present. This may not be required for older, adolescent children. After the sedative has taken effect, your child will be transferred to the treatment area (older children may receive a sedative in the treatment room while you are present). I will administer oxygen and monitor your child s heart rate, blood pressure, oxygen saturation, respiration, and body temperature. An intravenous line will be started and medications will be given as needed to keep your child comfortable, pain free, and asleep throughout the entire dental procedure. Accompanying adults (parents/guardians) will remain in the reception area during the entire treatment. This is to ensure that the doctors are able to completely focus their attention on your child, thereby ensuring maximum safety. If you are unsure of anything or have additional questions, do not hesitate to call Patricia, our office manager, at (516) We look forward to assisting you toward completion of your child s dental treatment with the highest quality of care and safety in the near future. Sincerely, The Physicians of General Anesthesia Services 75 Jackson Avenue, Syosset NY Office: (516) Fax: (516)

2 PEDIATRIC MEDICAL HISTORY QUESTIONNAIRE Parents, please take time to carefully fill out this questionnaire. Use the back of this form for additional comments. Patient s Name: Date of Birth: / / Age: Weight: lb Address: City: State: Zip: Parent s Names: Home: ( ) Cell: ( ) Date of Scheduled Treatment: / / Dentist/Surgeon s Name: Best Time to Call: List all medications currently being taken by your child (include vitamins, herbs, over-the-counter pills): Does your child have allergies to any medications or foods? If yes, list and state what happened? 1. Is your child in good health? Yes No 2. Was your child born prematurely? (if so, how many weeks) weeks. Complications? Did your child have a breathing tube? If yes, for a prolonged period? Yes No 3. Is your child currently or regularly under the care of a physician Yes No 4. Has your child had any serious illnesses, accidents, operations, or been hospitalized in the last 5 years? Yes No Please list: 5. Does your child have or has he/she had in the past any of the following heart diseases or complications? Yes No Circle all that apply: Congenital heart defects, Murmurs, Malfunctioning heart valves, Pacemaker, Arrhythmias or irregular heartbeats, Ventricular or Atrial Septal defects? 6. Does your child have or has he/she had in the past any of the following cardiovascular (heart) complications? Yes No Circle all that apply: Chest pain or cyanosis upon exertion, Shortness of breath on exertion High blood pressure, Stroke, Recurrent Fainting 7. Has your child had a recent nose, throat, chest cold or flu? Yes No How long has it been fully resolved? ( days / weeks ) Are there continued symptoms (example, cough, fever, home from school, nasal discharge)? Yes No 8. Does your child have or has he/she had in the past any of the following lung diseases or complications? Yes No Circle all that apply: Bronchitis, pneumonia, Chronic cough, Chronic sinus disease, Seasonal allergies 9. Has your child ever had Asthma? Yes No When was the last attack? (weeks / months / years) How severe and how often do the attacks occur? Does your child need daily asthma medication or do you just use medication as needed? Every day as needed Have steroid medications ever been used? If so, how often? Last use? 10. Does your child have Tonsil or Adenoid problems? Yes No 11. Has your child been diagnosed with Sleep apnea or is there loud snoring every night when sleeping? Yes No 12. Does your child have or has he/she had in the past any of the following diseases or complications? Yes No Liver (Hepatitis, jaundice)? Yes No Kidney (Kidney stones, Ureter or Bladder disorders, Renal insufficiency or failure)? Yes No Thyroid Disease or Diabetes? Yes No Stomach Problems (ulcers, excess stomach acid, or reflux, persistent diarrhea, weight loss)? Yes No Arthritis (swollen or painful joints or lymph nodes)? Yes No Muscle disorders or weakness (Low muscle tone, muscular dystrophy)? Yes No Seizures, Fainting Spells, Frequent Headaches, or other neurological problems? Yes No Mental Retardation, Depression, ADHD, Autism, PDD, or any other problems with mental health? Yes No Cancer, Sexually transmitted diseases, HIV, AIDS? Yes No 13. Does your child bruise easily or has he/she ever been diagnosed with a bleeding disorder? Yes No 14. Does your child have any blood disorders such as Anemia or Sickle Cell Anemia? Yes No 15. Has any blood relative of the patient ever had a bad or unusual reaction to anesthesia? Yes No 16. Does your child have any disease, disorder, or complication not mentioned above? Yes No If yes, please explain: Additional Comments: I I understand that that withholding any any information about about my my child s child s health health could could seriously seriously jeopardize his/her his/her safety. safety. Therefore, I have I have reviewed reviewed the the above above medical medical health health history history carefully carefully and and have have answered all all questions truthfully and and to to the the best best of of my my knowledge. I hereby I hereby give give permission to to Dr. the Boorin physicians to of discuss GAS, my LLP child s to discuss medical my child s health with medical other health health with professionals other health involved professionals with my involved child s with care.. my child s care. Parent Parent / / Guardian Signature: Printed Name: Name: Date: / / / / Martin

3 Medical Evaluation prior to Dental Surgery with General Anesthesia Please FAX this completed medical evaluation to (516) Please RETURN completed form to Parent [Parent should bring original on day of procedure] This pre-anesthetic HISTORY and PHYSICAL is to be completed by the patient s physician as close to the date of the scheduled procedure as possible. Please return a legible and signed evaluation note addressing general health, prior significant or current systemic disease or illness as well as the patient s current functional status. If other clinicians need to be consulted, or if specific pre-anesthetic medications or lab tests are recommended, please specify. Patient Name: DOB: Date of Treatment: Vital Signs: BP / P Temp RR Weight: Height: Summary History: Medications: Allergies: [ ] NKDA Smoking / ETOH / Drugs: Prior Surgery or Hospitalizations: PHYSICAL General Appearance: Well appearance [ ] Head and Neck: WNL [ ] Cardiovascular: WNL [ ] [ ] Congenital Heart Disease [ ] CAD [ ] Valvular Heart Disease [ ] Arrythmia [ ] PPM / AICD Pulmonary: WNL [ ] [ ] Asthma [ ] COPD [ ] Sleep Apnea Gastrointestinal: WNL [ ] [ ] Reflux [ ] Hiatal Hernia [ ] Dysmotility [ ] Dysphagia Renal: WNL [ ] Hepatic: WNL [ ] Endocrine: WNL [ ] [ ] Thyroid [ ] Diabetes Other Metabolic: WNL [ ] [ ] Obesity Musculoskeletal: WNL [ ] Neurological: WNL [ ] [ ] Cerebral Palsy [ ] PDD [ ] ADD/ADHD [ ] Seizures [ ] Developmental Delay(s) [ ] Neuropathy OB / GYN: WNL [ ] Available Lab Data: (EKG, Blood) Urine HCG Test [When appropriate] COMMENTS / RECOMMENDATIONS: Physician Name: Telephone: ( ) Signature: Date: / /

4 Financial Agreement Form Patient s Name: Dentist / Surgeon s Name: Date of Procedure / / Everyone benefits when definite financial arrangements are agreed upon in advance. Accordingly, we have prepared this material to acquaint you with our financial policy for payment of anesthesia services. Estimation of Anesthesia Fee: INITIAL 60 Minutes.. $ Anesthesia fees are based on units of time: $ 795 for the first 60 minutes of anesthesia Additional hours are charged at 15 min increments. ADDITIONAL 1 st Hour ($100 per 15 min) ADDITIONAL 2 nd Hour ($87.50 per 15 min) ADDITIONAL 3 rd Hour ($75 per 15 min) TOTAL DUE ON THE DAY OF SURGERY PAYMENT FOR ANESTHESIA SERVICES IS DUE IN FULL ON THE DAY OF TREATMENT: Anesthesia Fee Deposit: You are responsible for a deposit in the amount of $ at the time of booking the procedure with the surgical office. This deposit should be in the form of cash, credit card payment, or a personal check made payable to General Anesthesia Services, LLP. The check should be mailed to 75 Jackson Ave, Suite 204, Syosset NY All credit card deposits will be processed by the anesthesia office directly. Please contact General Anesthesia Services at for credit card payments. Cancellation of Procedure: If a planned procedure is cancelled within 10 days of the scheduled date, for any reason other than medical clearance issues or illness, you will forfeit a $500 cancellation fee. This fee will be deducted from the deposit for the procedure. If you return for surgery within 1 month of the original date of surgery, this fee will be credited towards the anesthesia fee due for the new surgical date. All deposits will be refunded within 10 days of the cancellation date, less any applicable cancellation fees as described above. A doctor s notes is required to confirm medical illness. Please note that if a patient is healthy and has no medical contraindications for anesthesia, failure to obtain clearance will count as a non-medical cancellation and the cancellation fee will apply for procedures canceled within 10 days of the procedure. Balance Payment for Anesthesia services: The first hour of any procedure will be billed at $795. Procedures that last longer than one hour will be billed at the rate of $400 for the second hour, $350 for the third hour and $300 for the fourth and each hour after that. A minimum fee of $795 is applicable for all procedures. After the minimum fee is met, rates are calculated based on 15 minute intervals of time. The calculation of the anesthesia fee is based on total time you are cared for in the operating room, from the time entering the O.R. until you are transferred to the recovery room personnel in stable condition. Balance payment will reflect total fees minus deposit at time of booking. Please have payment available upon arrival on the day of the scheduled surgery. Payment must be in the form of cash or credit card. We do not accept checks for the final payment. I have read, agree, and received a copy of the financial agreement and deposit policy. Signature: Print Name: Date: Credit Card (circle): MC Visa Discover Card AMEX#: Exp. Date: Deposit Amount: Required Verification Code (back of Card (3 numbers): The Cardholder acknowledges responsibility for payment of the non-refundable deposit and agrees to perform the obligations set forth in the cardholder s agreement with the issuer. Cardholder Signature: Cardholder Name: Date: Address: City: State: Zip:

5 The Pre-anesthetic instructions herein must be strictly adhered to before undergoing anesthesia and will make the scheduled dental treatment under anesthesia safe and successful. Neglecting any of the following instructions may compel the doctor to postpone the treatment The anesthesia deposit will be forfeited if children eat on the day of treatment unless instructed to do so EATING AND DRINKING MEDICATIONS CHANGES IN HEALTH HOME PREPARATION ARRIVING GETTING HOME HOME ACTIVITY PRE-ANESTHETIC INSTRUCTIONS Nothing to eat after midnight prior to your child s scheduled appointment unless otherwise instructed. Your Child is allowed moderate amounts of clear liquids (8 ounces) up to two (2) hours prior to the scheduled appointment. CLEAR LIQUID : Water, Apple juice, Clear jello, Gatorade DO NOT GIVE: Milk, Soup, Non-clear or Pulp-containing juice Prescription medications should be taken as per their regular schedule, unless previously discussed and modified by GAS, LLP. MEDICATIONS MUST ONLY BE TAKEN WITH A CLEAR LIQUID. Vitamins, herbal products, and non-prescription medications should not be taken. A change in your child s health, especially the development of a cold or fever, is very important. Inform our office of any change in their health that occurs prior to your child s appointment. For their safety, we may need to reschedule for another day. Make sure to give your child a good night s sleep before the day of the procedure. They should wear comfortable, loose fitting clothing. We suggest a short sleeve shirt, and a sweatshirt over it if needed. Contact lenses must be removed. A blanket and a change of clothing are suggested in case of accident. Arrive early enough to allow for a discussion of your child s health, a brief examination, consent for anesthesia and question answering. Children will be sleepy after the procedure and must be accompanied by at least one parent and another adult, one to drive and the other to attend to the child during the ride home. They must be seat belted in as they are less prepared to brace themselves during sudden stops. Do not take mass transportation (bus, train). Children may develop nausea on the ride home, be prepared. A responsible adult should remain with the patient until the next day. The child will NOT be able to attend school the next day. POST-ANESTHETIC INSTRUCTIONS After returning home, your child should rest for the remainder of the day and be observed. It is common for patients to be sleepy, dizzy or off-balance after receiving anesthetics. Children may return to school in two days if they have had an early to mid-day procedure and an uneventful night. EATING AND Upon arrival home, the first drink should be one ounce of water or clear fruit juice every 15 minutes for 1.5 DRINKING hours, followed by clear liquids and soft carbohydrate foods for an additional 1.5 hours. Give your child small drinks frequently, throughout the day. Hydration is more important than foods. Hold dairy and meats for at least 3 hours following your arrival home. POST TREATMENT Some common after-effects include sleepiness, dizziness, nausea, (may be worse after car ride home), EFFECTS soreness of mouth, jaws and throat, dry mouth, muscle aches and shivering. These symptoms may last for 1 to 3 hours, and on rare occasions somewhat longer. Children receiving treatment in the afternoon may be more sleepy afterward due to coinciding nap times. INTRAVENOUS SITE A very small percentage of patients experience post-operative tenderness and/or redness in their hand or arm which may be a chemical phlebitis associated with intravenous infusion. If this occurs please contact GAS, LLP at (516) immediately. If phlebitis (vein swelling) does occur the patient should receive an anti-inflammatory agent (ibuprofen/children s motrin). Apply warm compresses, and elevate the arm. SEEK ADVICE IF Vomiting persists beyond four hours on four separate occasions. Unable to drink liquids 4 hours after arrival at home. Temperature elevates rapidly or remains elevated. Please consult the ER and have Dr. Vali paged. PAIN MEDICATION Expect to give your child Tylenol or Ibuprofen after the procedure to minimize any throat, mouth or tooth soreness. This should be started on arrival at home and repeated every 4 hour (Tylenol) or 6 hour (Ibuprofen) intervals until the next day to ensure a good-nights rest. If Questions Arise, Please Contact Patricia at General Anesthesia Services: (516) Dr. Vali can be paged using office number: (914) I have read, understand and agree to follow the above instructions SIGNED: DATE: