Patient/Parent Instructions

Transcription

1 Patient/Parent Instructins Please cmplete the enclsed ANESTHESIA PATIENT INFORMATION frm, MEDICAL HISTORY frm and CREDIT CARD DEPOSIT frm. Mail, r fax the cmpleted frms t Sedadent Anesthesia Services tw weeks prir t yur appt. Read and carefully fllw the PRE-ANESTHESIA INSTRUCTIONS that are enclsed. Please read and keep the FINANCIAL POLICY and POST-ANESTHESIA INSTRUCTIONS. It is recmmended that yu immediately infrm yur insurance carrier f exactly what is happening. Recent changes have ccurred in Texas insurance law that nw require cmpanies regulated by Texas law t cver anesthesia services under yur Medical Plicy (NOT DENTAL) if they are needed fr any physical, mental, r medical reasn. It may require a shrt nte frm yur dentist that he requests sedatin r anesthesia. I will be happy t furnish yu r yur insurance cmpany with any necessary infrmatin. Please call at if yu have questins. D nt make the mistake f trying t deal with the insurance cmpany after the prcedure has been perfrmed. Read the ANESTHESIA CONSENT FORM. This frm is nt meant t scare r frighten yu, but infrm yu. Anesthesia services in dentistry have prven t be very safe and predictable. The dctr will discuss and answer any questins that yu may have befre any treatment is perfrmed. If yu have questins that yu wuld like t discuss befre yur appintment date, please feel free t call The dctr will als attempt t call yur hme the evening befre yur appintment t explain what t expect during yur visit. Please leave a cntact number that is readily available fr his call.

2 Anesthesia Patient Infrmatin Date: Patient Name (Last, First): DOB: Age: Height: Weight: MALE / FEMALE Respnsible party s name and phne number: Address: City: State: Zip: Hme: (_)_ Cell: (_) Wrk: (_) (s): Please circle the best number fr dctr t reach yu prir t yur appintment. INSURANCE INFORMATION Insured s Name (Last,First): DOB: Dental Insurance Carrier: Subscriber ID: Health Insurance Carrier: Subscriber ID: HEALTH INSURANCE CLAIM FORM (HICF 1500) Requested: Y N As part f the Affrdable Care Act, ur ffice is required t recrd meaningful use data fr each patient. Please answer the fllwing: RACE: ETHNICITY: American Indian r Alaska Native Hispanic r Latin Asian Nt Hispanic r Latin Black r African American Prefer Nt t Answer Native Hawaiian r ther Pacific PREFERRED LANGUAGE Islander English White Spanish Prefer Nt t Answer Other TREATMENT INFORMATION Estimated Length f Appintment: Estimated Fee: Appintment Date: Rendering Dentist: MEDICAL INFORMATION LIST OF CURRENT MEDICATIONS Medicatin: Dse Given: Frequency (i.e. 2X per day): LIST OF KNOWN MEDICAL CONDITIONS LIST OF KNOWN DRUG ALLERGIES

3 Medical Histry Patient s Name_Date f Birth / / Age_ Weight Street AddressCity State Zip Parent/Guardian name Relatinship t child Telephne Hme ( ) _-_ Mbile ( ) _-_ Wrk ( ) - List all patient medicatins: 1. Des yur child have any allergies r reactins t medicatins, fd r latex? If yes, explain _ 2. Des yur child have any prblems with their heart such as cngenital defects, murmurs, high bld pressure r shrtness f breath during play? If yes, explain_ 3. Des yur child have any prblems with their lungs like asthma, brnchitis, recent cld r flu, RSV r tuberculsis? If yes, explain_ 4. Des yur child have any prblems with their stmach/abdmen such as reflux, nausea r difficulty swallwing? If yes, explain_ 5. Des yur child have any prblems with their glands like diabetes, thyrid prblems, pancreas r ther? If yes, explain_ 6. Des yur child have any prblems with their muscles such as weakness, paralysis, spasticity, muscular dystrphy? If yes, explain_ 7. Des yur child have prblems with any f their nerves, like seizures, palsy, retardatin, strke, Dwns syndrme, autism, ADHD? If yes, explain_ 8. Des yur child have any prblems with their kidneys such as kidney failure, infectins r dialysis? If yes, explain_ 9. Des yur child have any prblems with their bld like hemphilia, frequent nse bleeds, anemia, pr cltting, sickle cell, HIV r transfusins? If yes, explain_ 10. Have yu r yur child r bld relative ever had prblems with general anesthetics? If yes, explain_ 11. Please list all serius illnesses r hspitalizatins and dates. 12. Please list all surgical peratins and dates. I understand that the accuracy f my child s health histry is critical t the safety f general anesthesia. I have carefully answered all questins truthfully and t the best f my knwledge. Patient/Guardian Signature_ Date

4 CREDIT CARD DEPOSIT/PAYMENT FOR GENERAL ANESTHESIA PLEASE WHEN APPOINTMENT IS MADE OR FAX TO PATIENT NAME: DENTIST OFFICE: DATE SCHEDULED: Please circle the type f card: VISA MASTERCARD AMERICAN EXPRESS DISCOVER CARE CREDIT Credit Card #_ EXP DATE SECURITY CODE (ON BACK OF CARD) BILLING ADDRESS ADDRESS AMOUNT DEPOSIT - $ < 90 MINUTES - $900 > 90 MINUTES - $1200 Depsit is due n date f scheduling. Full amunt is due at least ne day prir t treatment date. I authrize t charge the abve referenced card fr the amunt indicated. Any additinal balance due after the prcedure may be charged indicated unless ther arrangements have been made. Signature _

5 Anesthesia Cnsent Frm The fllwing is prvided t infrm patients f the chices and risks invlved with having treatment under anesthesia. This infrmatin is nt presented t make patients mre apprehensive, but t enable them t be better infrmed cncerning their treatment. I hereby authrize and request and it s cntracted prviders t perfrm the anesthesia as previusly explained t me, and any ther prcedures deemed necessary r advisable as a crllary t the planned anesthesia. I cnsent, authrize and request the administratin f such anesthetic r anesthetics (lcal t general) by any rute that is deemed suitable by the anesthesilgist, wh is an independent cntractr and cnsultant. It is the understanding f the undersigned that the anesthesilgist will have full charge f the administratin and maintenance f the anesthesia, and this is an independent functin frm the surgery I understand that prcedures nt discussed, but deemed necessary, may be perfrmed. Listed belw are cmplicatins that may be assciated with general anesthesia. Serius cmplicatins are very rare. The alternative ptins fr sme patients include intravenus cnscius sedatin r nitrus xide/xygen sedatin with lcal anesthesia r lcal anesthesia alne. Initial each Cmmn Cmplicatins Assciated with General Anesthesia Pain and/r bruising at yur intravenus (IV) site Sre thrat and/r harseness Muscle aches Nausea and/r vmiting Uncmmn Cmplicatins Assciated with General Anesthesia Headache Injuries t lip r teeth frm airway instruments and/r devices Unexpected drug reactin Infectin at intravenus site and veins nearby Bleeding/Injury t nse due t passage f tubes Lung Infectin Eye injury t infectin Weakness in breathing after awakening Nerve damage Rare Cmplicatins Assciated with General Anesthesia Heart injury due t unexpected anesthetic reactin Brain damage r death I understand that anesthetics, medicatins, and drugs may be harmful t the unbrn child and may cause birth defects r spntaneus abrtin. Recgnizing these risks, I accept full respnsibility fr infrming the anesthesilgist f the pssibility f being pregnant r cnfirmed pregnancy with the understanding that this will necessitate the pstpnement f the anesthesia. Fr the same reasn, I understand that I must infrm the anesthesilgist if I am a nursing mther. Signed Print Name

6 The Health Insurance Prtability and Accuntability Act (HIPAA) Patient Name Date f Birth HIPAA is the acrnym fr the Health Insurance Prtability and Accuntability Act f The Administrative Simplificatin prtin f HIPAA required the U.S. Department f Health and Human Services t establish natinal standards fr electrnic health care transactins and natinal identifiers fr prviders, health plans, and emplyers. It als addresses the security and privacy f health data. T h e Ntice f Privacy Practices describes plicies in regard t HIPAA. This ntice describes hw medical infrmatin abut yu r yur child may be used and disclsed and hw yu can get access t this infrmatin. Please review it carefully and sign belw. Yes, I've read Ntice f Privacy Practices Signature f Patient r Parent/Guardian_ Print Name Date

7 Financial Plicy Since everyne benefits when definitive financial arrangements are agreed upn in advance, we have prepared this material t acquaint yu with ur financial plicy fr anesthesia services. Anesthesia services prvided in the ffice setting cnsiderably lwers the cst f care when cmpared t care prvided in a hspital r utpatient surgical center. Fees can be kept lw by utilizing the equipment and facilities yur dctr has already prvided. The anesthesia fee is based n yur dctr s time fr the prcedure. As such, the time estimate may vary based n surgical cmplexity r anesthesia preparatin time. The anesthesia billing perid is frm the time yu are seated until the recvery is cmpleted. Because f the pre-surgical preparatin required by t prvide safe, quality care and the scheduling f ur case t the exclusin f ther ffices and patients, a depsit must be paid prir t the scheduling f the case. The depsit will be applied t the ttal anesthesia charges the day f the prcedure. The balance f the anesthesia charges will be due the day the service is prvided, prir t sedatin. T cnfirm anesthesia services fr yur appintment, ur ffice will cllect a $300 minimum depsit n the day that the appintment is scheduled. If the appintment is in less than 7 days, please call the ffice and pay the depsit with a credit card (Nte: The depsit is nn-refundable if the appintment is canceled and nt rescheduled with less than 2-wrking days ntice t ur ffice, regardless f reasn.). The balance f the fee is due prir treatment. The fee fr anesthesia including all pre-anesthesia evaluatins, cnsultatins with physicians if necessary, all drugs, supplies, anesthetic care and recvery is as fllws: The fee fr services lasting less than ne and ne-half hur (1 ½ hr) $800. The fee fr services lasting mre than ne and ne-half hur (1 ½ hr)_$1200. Arrangements will be made with the dctr fr services lasting lnger than three (3) hurs. We accept cash, mney rders, MasterCard, Visa, Discver, and American Express and Care Credit. All payments shuld be made payable t: INSURANCE Althugh we d nt accept insurance as direct payment fr ur services, ur ffice will gladly assist yu with the prcessing f yur insurance frm s yu may be reimbursed frm yur insurance prvider directly. Recent changes have ccurred in Texas laws that have dramatically increased the cverage prvided under many health insurance plans fr anesthesia fr dentistry. Hwever, we still recmmend that yu check with yur carrier befre treatment t determine any plicy limitatin r c-payment. We will wrk with yu and yur carrier by prviding infrmatin t insure that yur claim is prcessed prperly. Shuld yu have any questins regarding ur services r financial arrangements, please d nt hesitate t cntact us.

8 PRE - ANESTHESIA INSTRUCTIONS Drinking and Eating: In rder t decrease the risk f cmplicatins during anesthesia, it is VERY IMPORTANT that yur child des NOT have ANYTHING TO EAT OR DRINK eight (8) hurs befre their scheduled dental prcedure. During anesthesia the muscles abve the stmach can relax, releasing stmach cntents int the lungs. This can lead t serius cmplicatins including death. Yur child may have CLEAR liquids nly, up t tw (2) hurs befre their prcedure. Examples f clear liquids include water, apple juice, r Gatrade. Children cnsuming fd, MILK, range juice r ther nn-clear liquids within eight (8) hurs will be rescheduled. Clthing: Lse clthing with shrt sleeves is desirable, as are tw-piece utfits, t allw easy mnitr placement. Cntact lenses must be remved befre the appintment. D nt wear fingernail plish the day f appintment. Fr children, a change f clthing is recmmended fr unexpected urinatin. Please take yur child t the restrm upn arrival at the dental ffice. Change in Health: Please infrm the dctr f any change in yur health prir t yur appintment. The develpment f a cld r fever can increase the risks f anesthesia. Sick children will be reappinted fr safety reasns. Medicatin: Please fllw yur regular schedule f medicatins unless therwise directed by the dctr. Medicatins may be taken with nly a small sip f water. Accmpanied by an adult: A respnsible adult must accmpany all anesthesia patients t and frm the appintment. The respnsible adult shuld remain in the ffice during the appintment unless therwise authrized by the practitiner. A respnsible adult must drive the patient hme. (Buses r cabs are unacceptable) Questins r Cncerns: Please expect a call frm the dctr the night befre the appintment t answer any questins r cncerns. Please cntact if yu have any ther questins r cncerns: (512)

9 POST - ANESTHESIA INSTRUCTIONS Immediately Fllwing: Kicking, crying, screaming and cughing are all very nrmal immediately fllwing anesthesia. This will cntinue fr apprximately 15 minutes after waking frm anesthesia and will ccasinally cntinue until yu leave the ffice. Once the medicatin has wrn ff and yur child is fully awake, this will stp. Hme: Yur child will nrmally sleep fr ne r tw hurs after yu return hme frm yur dental visit. Upn awakening, yur child will usually resume nrmal activity. A respnsible adult shuld be with the patient until the next day. Drinking and Eating: Yur child may resume drinking immediately after yur dental visit. Yu shuld begin with clear liquids (water, apple juice, Gatrade) and prgress their diet t sft fds (applesauce, ygurt, atmeal, etc.). Ppsicles/ice cream are ften very sthing t yur child s thrat and can be given t yur child right away. If sft fds are tlerated well, yu may resume a nrmal diet. Intravenus Site (IV): A small percentage f patients experience pst-perative tenderness and/r redness at the IV site. Bruising is cmmn and expected, but swelling/increasing redness is nt nrmal. If this ccurs, call Sedadent Anesthesia Services at (512) Sre Thrat: Yur child had a breathing tube placed nrmally in the right side f the nse. If yu ntice redness r small amunts f bld when yur child blws his/her nse, this is als nrmal. Yur child may als cmplain f a sre thrat as a result f the breathing tube fr up t three days fllwing surgery. Pain Cntrl: Yur child was given a pain medicatin thrugh the IV that is very similar t the drug Ibuprfen. This shuld last fr 4 (fur) hurs fllwing yur visit. Please refrain frm giving yur child any pain medicatin cntaining Ibuprfen (Mtrin, Advil) as this culd verdse yur child n that medicatin. If yu feel yur child is in pain upn returning hme, yu are encuraged t give children s Tylenl. Seek Advice: Please call if vmiting persists beynd 4 hurs, r if the temperature remains elevated beynd 24 hurs, r if any ther matter causes cncern. If yu feel yur child is nt well fr any reasn fllwing anesthesia, please call Sedadent Anesthesia Services at (512) Questins r Cncerns: Call at (512)