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Dental Practices
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Sedation
Services
Team
Information
Contact Us
Dental Practices
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PATIENT'S DETAILS
Patient's Name
*
First
Last
Patient's Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Patient's Date of Birth
*
Date of birth
Patient's Phone
*
Mobile phone number
Patient's Email
*
Email address
PRACTICE DETAILS
Practice Name
*
Practitioner
*
Practitioner performing the procedure for the patient
TREATMENT
Proposed Treatement
*
Extractions
Implants
Restorations
Scale & Clean
Periodontal
Impressions
Crown / Bridge
Other
Expected Treatment Duration
*
1h
1.5h
2h
>2h
INFORMATION
Sedation information provided to patient
*
Completed
Sedation Instructions provided to patient
*
Completed
Sedation pricing discussed with patient
*
Completed
Sedation written consent obtained
*
Completed
Online medical history link provided to patient to complete
*
Completed
APPOINTMENT
Appointment details
Appointment 1
*
Date
Time
Appointment 2
Date
Time
Appointment 3
Date
Time
Name of person completing this form
*
Submit
