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applying emla patch

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August 6, 2018 admin 0 Comment

WHAT IS THE EMLA PATCH?

EMLA is a mixture of two local anesthetics, lignocaine and prilocaine. These local anesthetics are […]

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Medical Questionnaire

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Dentist / Surgeon*

Did any family member have an anesthetic related complication?*

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I have completed the above questionnaire to the best of my knowledge and did not withhold any information.*

I understand that if there is anything I would like to discuss in person and not mention in the questionnaire, I will contact my treating doctor*

Account Details

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Consent Form

Please read carefully through the below consent form, making sure you understand by ticking each box.

I have been informed and declare the following:*

I understand the basis of sedation, the purpose of the procedure and the risks involved.

I understand:*

No guarantee can be given with regards to the results obtained.

I understand:*

All the aspects of sedation are explained on the website www.sedation.co.za and the I can request the sedationist to contact me if there is any concerns.

I understand:*

Unforeseen complications may arise during sedation that may require additional or different medication or treatment. I authorize the sedationist to treat such complications according to his/her professional judgement.

I understand:*

The post sedation instructions and will abide by them. I have completed a medical history questionnaire and have declared all drugs that I have been taking for the last 6 months.

I understand:*

I am strongly advised not to drive any motorized vehicle, work with power tools or enter into any legal contract until the following day.

Terms and Conditions of Payment

Please read carefully through the following to make sure you understand the terms and conditions of payment.*

The sedation account rendered is completely independent from the accounts rendered by the hospital and surgeons. I accept full and complete responsibility for settlement of the account and declare that I understand and have been informed of the fees to be charged. I acknowledge that the practice charge private rates that may be more than medical aid rates. I understand that it is my own responsibility to obtain authorization from my medical aid prior to the procedure if it was arranged to be claimed on my behalf. In the event of no payment after 90 days, my account will be handed over to n independent company for collection. I understand that if the account is not settled, I will be liable for all costs involved in any legal proceedings regarding the recovery of debt. I accept the fees charged by the practice. If my medical aid pays less that the claimed amount, I will be liable for the difference. If I cancel the sedation within 48 hours of my appointment, without a legitimate medical reason, a cancellation fee will be charged.

I have read, understood and agree to the conditions mentioned above.*

I hereby give permission for sedation on myself or my dependent

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