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January 7, 2012 admin 0 Comment

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Sedation Application

Please take your time and fill out the form below

Step

1

of

5

Patient Information:

Title*

First Name*

Last Name*

Date of Birth*

Contact Number*

Age

Height

Weight

Sex

Medical Questionnaire

Date of planned procedure*

Dentist / Surgeon*

Did any family member have an anesthetic related complication?*

Yes

No

If your answer was yes, please provide us with more information.*

Are you allergic to any medication, food (eggs or soya) or substance?*

Yes

No

If your answer was yes, please provide us with more information.*

Any problems with the birth process?*

Yes

No

If your answer was yes, please provide us with more information.*

Premature birth?*

Yes

No

If your answer was yes, please provide us with more information.*

Are you pregnant?*

Yes

No

If your answer was yes, please provide us with more information.*

Are you breastfeeding?*

Yes

No

If your answer was yes, please provide us with more information.*

Cardiovascular

Do you suffer from high blood pressure?*

Yes

No

If your answer was yes, please provide us with more information.*

Do you suffer from heart failure?*

Yes

No

If your answer was yes, please provide us with more information.*

Do you suffer from heart valve lesions?*

Yes

No

If your answer was yes, please provide us with more information.*

Do you suffer from irregular heart rate or palpitations?*

Yes

No

If your answer was yes, please provide us with more information.*

Respiratory

Do you suffer from snoring/sleep apnoea?*

Yes

No

If your answer was yes, please provide us with more information.*

Do you suffer from asthma or other lung diseases?*

Yes

No

If your answer was yes, please provide us with more information.*

Do you suffer from the flu or had chest infection in the last 4 weeks?*

Yes

No

If your answer was yes, please provide us with more information.*

Do you smoke? If yes, how many cigarettes a day?*

Yes

No

If your answer was yes, please provide us with more information.*

Central Nervous System

Do you suffer from Epilepsy?*

Yes

No

If your answer was yes, please provide us with more information.*

Do you suffer from depression or psychosis?*

Yes

No

If your answer was yes, please provide us with more information.*

Do you suffer from ADHD/hyperactivity?*

Yes

No

If your answer was yes, please provide us with more information.*

Do you suffer from Autism?*

Yes

No

If your answer was yes, please provide us with more information.*

Endocrine

Do you suffer from Diabetes?*

Yes

No

If your answer was yes, please provide us with more information.*

Do you suffer from Thyroid problems?*

Yes

No

If your answer was yes, please provide us with more information.*

Do you suffer from Porphyria?*

Yes

No

If your answer was yes, please provide us with more information.*

Are you on any Steroid therapy?*

Yes

No

If your answer was yes, please provide us with more information.*

Liver

Do you suffer from any liver disease, hepatitis etc?*

Yes

No

If your answer was yes, please provide us with more information.*

Any history of jaundice?*

Yes

No

If your answer was yes, please provide us with more information.*

Do you consume more than 7 alcoholic beverages / week?*

Yes

No

If your answer was yes, please provide us with more information.*

Kidneys

Do you suffer from any kidney or bladder disease?*

Yes

No

If your answer was yes, please provide us with more information.*

Drugs

Do you take any medication (including herbal)?*

Yes

No

If your answer was yes, please provide us with more information.*

Have you had any adverse/unpleasant reaction to anesthetics in the past or failed sedation?*

Yes

No

If your answer was yes, please provide us with more information.*

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

Person responsible for the account

Title

First Name*

Last Name*

ID Number*

Employer

Home Address*

Postal Address

Work Telephone Number

Mobile Number*

Email*

Confirm Email

Do you have a Medical Aid?

No Yes

Medical Aid Details

For account purposes only

Medical Aid*

Medical Aid Plan*

Medical Aid Number*

Dependent Code

Main Member*

Authorization Code

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

Name of Patient*

Date*

Signature

Name and Surname*

If you don't see the signature field or not able to sign, please enter your name and surname which will act as your digital signature

Time stamp

When entering your name, please be sure to enter the time (approx).

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