Sedadent Anesthesia Services Jarom Heaton D.D.S., M.S. Instructions:
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1 Sedadent Anesthesia Services Jarom Heaton D.D.S., M.S. Instructions: To Dental Staff: Please fill out the Anesthesia Patient Information form and fax to Dr. Heaton s or drop in the mail to the address below: Sedadent Anesthesia Services Phone: Dr. Jarom Heaton Fax: Shellcastle sedadentanesthesia@gmail.com Suite 100 Website: Round Rock, Texas To the Patient/ Parent: Please read and carefully follow the Pre-Anesthesia Instructions that are enclosed. Please fill out and return the enclosed to Sedadent Anesthesia Services: Medical History Form Consent Form Deposit of $ It is recommended that you immediately inform your insurance carrier of exactly what is happening. Recent changes have occurred in Texas insurance law that now require companies regulated by Texas law to cover anesthesia services under your Medical Policy (NOT DENTAL) if they are needed for any physical, mental or medical reason. It may require a short note from your dentist that he requests sedation or anesthesia. I will be happy to furnish you or your insurance company with any necessary information. Do not make the mistake of trying to deal with the insurance company after the procedure has been performed. Read the Informed Consent for Anesthesia. This form is not meant to scare or frighten you, but inform you. Anesthesia services in dentistry have proven to be very safe and predictable. I will discuss and answer any questions that you may have before any treatment is performed. If you have questions that you would like to discuss with me before the appointment date, please feel free to call Dr. Heaton will also attempt to call your home the evening before our appointment to explain what to expect during your visit. Please leave a contact number that is readily available for his call.
2 Financial Arrangements: Since everyone benefits when definitive financial arrangements are agreed upon in advance, we have prepared this material to acquaint you with our financial policy for anesthesia services. Anesthesia services provided in the office setting considerably lower the cost of care when compared to care provided in a hospital or outpatient surgical center. Fees can be kept low by utilizing the equipment and facilities your doctor has already provided. The anesthesia fee is based on your doctor s time for the procedure. As such, the time estimate may vary based on surgical complexity or anesthesia preparation time. The anesthesia-billing period is from the time you are seated until the recovery is completed. Because of the pre-surgical preparation required by Sedadent Anesthesia Services to provide safe, quality care and the scheduling of our case to the exclusion of other offices and patients, a deposit must be paid prior to the scheduling of the case. The deposit will be applied to the total anesthesia charges the day of the procedure. The balance of the anesthesia charges will be due the day the service is provided. To confirm anesthesia services for your appointment, a minimum deposit of $300 will need to be sent to our office the day that the appointment is selected. If the appointment is in less than 7 days, please call the office and pay the deposit with a credit card (Note: The deposit is non-refundable if the appointment is cancelled and not rescheduled with less than 2 working day s notice to our office, regardless of reason). The balance of the fee is due at the time of treatment. The fee for anesthesia, including all preanesthesia evaluations, consultations with physicians if necessary, all drugs, supplies, anesthetic care and recovery is as follows. The fee for services lasting less than one and one-half (1 ½ hr) is $800. The fee for services lasting more than one and one-half hour (1 ½ hr) is $1200. Arrangements will be made with Dr. Heaton for services lasting longer than three (3) hours. We accept cash, money orders, MasterCard, Visa, Discover, & American Express. Insurance: Although we do not accept insurance as direct payment for our services, our office will gladly assist you with the processing of your insurance form so you may be reimbursed from your insurance provider directly. Recent changes have occurred in Texas laws that have dramatically increased the coverage provided under many health insurance plans for anesthesia for dentistry. However, we still recommend that you check with your carrier before treatment to determine any policy limitation or co-payment. We will work with you and your carrier by providing information to insure that your claim is processed proplerly. Should you have any questions regarding our services or financial arrangements, please do not hesitate to or sedadentanesthesia@gmail.com All payments should be made payable to: Sedadent Anesthesia Services
3 Medical History Form Dr. Jarom Heaton 3517 Shellcastle, Ste. 100 Referring Dentist: Bert C. Vasut, D.D.S. Round Rock, TX Sam F. Alzayat, D.D.S. Phone: Fax: Short Form history & Physical Examination (for Pediatric Dentistry under General Anesthesia) Please Fax to ASAP upon completion Patient Name: Date of Birth: Chief complaint: Present Illness: Family History: Past History and Hospitalizations: _ Birth and Neonatal History: Medications: Drug Reactions: Bleeding Tendencies: EENT: Cardio-Respiratory: Genito-Urinary: Gastro-Intestinal: Neurological: Physical Examination: T P R BP HT WT SA General Appearance: Head: Eyes: Ears: Nose: Throat: Tonsils: Neck: Lungs: Heart: Pulses: Abdomen: Genitalia: Rectal: Neurological: Impression on admission: Additional Information: Examining Physician: Date of Examination:
4 Consent Form for Sedadent Anesthesia Services JAROM HEATON D.D.S., M.S. The following is provided to inform patients of the choices and risks involved with having treatment under anesthesia. This information is not presented to make patients more apprehensive, but to enable them to be better informed concerning their treatment. I hereby authorize and request Dr. Jarom Heaton to perform the anesthesia as previously explained to me, and any other procedures deemed necessary or advisable as a corollary to the planned anesthesia. I consent, authorize and request the administration of such anesthetic or anesthetics (local to general) by any route that is deemed suitable by the anesthesiologist, who is an independent contractor and consultant. It is the understanding of the undersigned that the anesthesiologist will have full charge for the administration and maintenance of the anesthesia, and this is an independent function from the surgery. I understand that procedures not discussed, but deemed necessary, may be performed. Listed below are complications that may be associated with general anesthesia. Serious complications are very rare. The alternative options for some patients include intravenous conscious sedation or nitrous oxide/ oxygen sedation with local anesthesia or local anesthesia alone. ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ Please read the following statements below and sign your initials on the line provided. Common Complications Associated with General Anesthesia Pain and/ or bruising at your intravenous (IV) site Sore throat and/ or hoarseness Muscle aches Nausea and/ or vomiting Uncommon Complications Associated with General Anesthesia Headache Injuries to lip or teeth from airway instruments and/ or devices Unexpected drug reaction Infection at intravenous site and veins nearby Bleeding/ injury to nose due to passage of tubes Lung Infection Eye injury to infection Weakness in breathing after awakening Nerve damage Rare Complications Associated with General Anesthesia Heart injury due to unexpected anesthetic reaction Brain damage or death I understand that anesthetics, medications, and drugs may be harmful to the unborn child and may cause birth defects or spontaneous abortion. Recognizing these risks, I accept full responsibly for informing the anesthesiology of the possibility of being pregnant or confirmed pregnancy with the understanding that this will necessitate the postponement of the anesthesia. For the same reason, I understand that I mush inform the anesthesiologist if I am a nursing mother. Signature: Print Name: Witness: Date:
5 Pre-Anesthesia Instructions The instructions herein must be strictly adhered to before commencing with anesthesia. Neglecting any of the following may compel the doctor to cancel the start of treatment. Eating and Drinking: ABSOLUTELY DO NOT EAT OR DRINK ANYTHING after mid-night the day before your scheduled appointment. Accompanied by an Adult: All sedation patients must be accompanied to and from the appointment by a responsible adult. The responsible adult should remain in the office during the appointment unless otherwise authorized by the practitioner. Medications: Medications normally taken should be taken unless otherwise agreed upon by this office, and may be taken only with a sip of water. Clothing and Makeup: Casual clothing with short sleeves is desirable, as are two piece outfits, to allow easy monitor application. Contact lenses must be removed before the appointment. Do not wear fingernail polish the day of appointment. For children, a change of clothing is recommended for unexpected urination. Change in Health: A change in your health, especially the development of a cold or fever is very important. For your safety, you may be re-appointed for another day. Please inform this office of any changes in your health prior to you appointment. Getting Home: The patient must be driven home by a responsible adult (buses or cabs are unacceptable.) Post-Anesthesia Instructions Home: A responsible adult should be with the patient until the next day. It is normal for you or your child to be tired the remainder of the day. It is important that you remain supervised because your reaction time may be delayed. Rest: Go home and rest for the remainder of the day. Do not drive a motor vehicle or perform any hazardous tasks for the remainder of the day. Eating and Drinking: Food and beverage may be taken when desired. It is recommended that you begin with clear liquids. If liquids are tolerated, you may continue with soft foods. Avoid hot spicy foods. No alcoholic beverages for 24 hours. A feeling of nausea may occasionally develop after sedation. o The following may help you feel better: Lying down for a while & a glass of cola beverage. Intravenous Site: A small percentage of patient s experience post-operative tenderness and / or redness at the IV site. If this occurs, call Dr Seek Advise: Please call the above number if vomiting persists beyond four hours, or if the temperature remains elevated beyond twenty-four (24) hours, or if any other matter causes concern. Questions or Concerns, call Dr. Heaton at: Sedadent Anesthesia Services, PLLC
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