Medical History and Consent Logo
Language
  • English (US)
  • Español
  • Português
  •  - -
  •  - -

  • Anesthesia Medical History Form

    • Basic Information 
    •  - -

    • Parents of Minor Patients:

      Please note that the pronoun "you" from this point onward will refer to your child, even though you (the parent) may be completing the form.

      Please be careful not to enter your (the parent's) medical information, as this could lead to confusion and may lead to misinterpretation of risks.

    • History and Physical 
    • Height and Weight 

    • BMI

    • Symptoms 
    • Medical History 

    • Do you have (or have you had) any of the following conditions?

    • Cardiac 

    • Cardiac

    • Neuro/Psych 

    • Neuro/Psych

    • Please be sure NOT to stop your seizure medications before anesthesia. Continue all seizure medications as normal.

      • If you need to take your seizure medications during the fasting period, you may do so with less than 3oz of clear water (no other liquids are allowed)
      • If you are only able to take your seizure medications with solids (apple sauce, peanut butter, etc.), please let us know as we may need to adjust your appointment.
      • Abruptly stopping your seizure medications (unless instructed by the prescribing physician) can lead to complications.

    • Please do NOT adjust or abruptly stop your ADHD medications before anesthesia, unless instructed by the prescribing physician. Continue all ADHD medications as you would on a normal basis. 

      • If you need to take your ADHD medications during the fasting period, you may do so with less than 3oz of clear water (no other liquids are allowed)
    • Respiratory 

    • Respiratory

    •  - -

    • Please be sure NOT to stop your asthma medications and inhalers before anesthesia. Continue all asthma medications and inhalers as normal.

      • Please bring your inhaler with you to the appointment.
      • Abruptly stopping your asthma medications (unless instructed by the prescribing physician) can lead to complications.
    • Endocrine 

    • Endocrine

    • The dose/schedule of your Diabetes Medications (including Insulin) will need to be adjusted before your anesthesia to prevent hypoglycemia (low blood sugar) and related complications.

      Please be sure to contact your physician and request dose adjustments before your anesthesia appointment.

      Let us know if you need help with this process.

    • GI/Renal 

    • Gastrointestinal/Renal

    • Genetic/Developmental 

    • Genetic/Developmental

    • Heme 

    • Bleeding Disorders

    • Substance Use 

    • Substance Use

    • Misc 

    • Miscellaneous

    • Medications and Allergies 

    • For surgical procedures, your Blood Thinners may need to be stopped beforehand to prevent excessive bleeding. 

      If you're undergoing surgery, please be sure to contact your physician and request schedule adjustments before your appointment.

      Let us know if you need help with this process.

    • The medication indicated in the above question must be stopped before your anesthesia to prevent serious complications.

      Please obtain permission from your physician to SKIP one dose before your anesthesia. This means:

      • If you take/inject these medications daily, skip one day before your appointment
      • If you take/inject these medications weekly, skip one week before your appointment

      These medications include but may not be limited to the following:

      • Ozempic
      • Mounjaro
      • Weagovy
      • Saxendra
      • Trulicity
      • Bydureon
      • Byetta
      • Victoza
      • Adlyxin
      • Rybelsus

       Please let us know if you need help discussing this with your physician.

    • Anesthesia and Surgical History 
    • Overview and Signature 
    • Clear
    • TX Preoperative Checklist Items 

  • Anesthesia Informed Consent

    Risks, benefits, and alternatives to Office-Based Dental Anesthesia

  • Han Anesthesiology (DBA "The Dream Pros") provides Dental Anesthesia services to patients undergoing dental treatments in an office-based non-hospital environment ("Office-Based Dental Anesthesia"). Dental Anesthesia services encompass the administration and management of mind-altering substances and numbing injections to facilitate dental care. Such provision of anesthesia is within the scope of Dental Anesthesiology, a specialty of Dentistry. The term "Dental Anesthesiologist" refers to a dentist who has completed a specialty training in Dental Anesthesiology.

    This form will provide you information about the risks, benefits, and the alternatives to receiving anesthesia from a Dental Anesthesiologist in a office-based non-hospital environment, so that the patient (or the parent/guardian of a minor patient) can make an informed decision about your (or your minor child's) dental treatment options.


    I. SEDATION AND GENERAL ANESTHESIA

    Administration of mind altering medications renders the patient into Sedation and/or General Anesthesia, the lightest of which is referred to as "Minimal Sedation", and the deepest of which is referred to as "General Anesthesia". These reflect different depths (or awareness levels) of anesthesia in the following order:

    1. Minimal Sedation (most awake / least risks)
      1. Low risks of Complications and Adverse Outcomes (further explained in Section IV below)
      2. Highest possibility of awareness
    2. Moderate Sedation
    3. Deep Sedation
    4. General Anesthesia (most unconscious / most risks)
      1. Low possibility of awareness (In any case, there is no guarantee of complete unawareness whatsoever)
      2. Highest risks of Complications and Adverse Outcomes

    The risks of Complications and Adverse Reactions exists even in the minimal or safest level of anesthesia.

    Dental Anesthesiologists are licensed to provide all level of anesthesia up to General Anesthesia. Any dentists, including general dentists and pediatric dentists may be licensed to provide Minimal Sedation and Moderate Sedation.

     


    II. LOCAL ANESTHESIA is the administration of injections to numb the area of the dental procedure, which may be used in conjunction with Sedation or General Anesthesia. Local Anesthesia also carries certain risks, which may include:

    • Pain
    • Swelling
    • Infection
    • Bleeding
    • Discoloration
    • Temporary or permanent numbness at the area of injection
    • Temporary or permanent nerve damage at the area of injection
    • Seizures
    • Heart attack
       

    III. ACCESS TO DENTAL TREATMENT

    Sedative and General Anesthesia is utilized to facilitate access to dental treatment for patients with:

    • Dental phobia
    • Special needs
    • Otherwise unable to, or have difficulty cooperating with dental procedures

    Office-Based Dental Anesthesia may provide more convenient access to dental treatment compared to the hospital environment. Office-Based environment may also put certain patients at a more psychological ease than the Hospital Environment. On the other hand, administration of Sedation and/or General Anesthesia in an Office-Based environment is associated with higher risks of Complications and Adverse Outcomes compared to Sedation and/or General Anesthesia administered in a Hospital setting.


    IV. RISKS OF COMPLICATIONS AND ADVERSE OUTCOMES

    Sedative and General Anesthesia is associated with risks of Complications and Adverse Outcomes, which may include: 

    • Nerve injury
    • Life threatening allergic reaction
    • Respiratory arrest
    • Pneumonia
    • Kidney injury
    • Stroke
    • Brain injury
    • Heart attack
    • Cardiac arrest
    • Death

     

    V. FREQUENT SIDE EFFECTS of Sedation and General Anesthesia include: 

    • Drowsiness
    • Lack of proper coordination
    • Impaired judgment
    • Pain
    • Nausea and vomiting
    • Phlebitis (raised, tender, hardened, inflammatory response at the intravenous site) 
    • Confusion

    The inflammation from a phlebitis usually resolves with local application of warm moist heat; however tenderness, discoloration, and a hard lump may be present up to a year. A breathing tube placed in the patient’s airway during general anesthesia may also cause a sore throat, which generally may last a few days.


    VI. AFTER THE ANESTHESIA

    You (or "your child" if you are a parent of a pediatric patient) will remain in a vulnerable mental and physical state for several hours after the termination of the anesthesia due to the residual effects of the anesthetics, including but not limited to confusion, impaired judgment, lack of physical coordination, and sedation. To mitigate the risks of physical injury and other adverse consequences, you must remain in physical proximity and under the direct care and supervision of a responsible adult for at least twenty-four hours following the termination of the anesthesia. During this period, the you are prohibited from driving, operating dangerous devices, exercising, playing sports, riding the bicycle, or engaging in any other activities which may pose you at risk of physical injury. You must also NOT sign any important documents NOR make significant life decisions during this period.

     


    VII. MISCELLANEOUS

    Anesthetics may be harmful to the unborn child and may cause birth defects or spontaneous abortion. 
    Use of controlled substances may pose fatal complications in combination with anesthesia. Such substances are prohibited for at least 24-hours after the termination of the anesthesia. Any planned use of pain medications within 24-hours after the anesthesia must be disclosed and consulted with the anesthesiologist.
    Any food or drink in the stomach during anesthesia poses serious and fatal injuries, including pneumonia, brain injury, and death. Patients are required to adhere to the fasting guidelines which will be provided to you in the days prior to your appointment. Minor patients must be strictly monitored and managed by a parent or similarly responsible adult to ensure that the patient adhere to the fasting requirements prior to the anesthesia.

     

    IIX. PROPOSED ANESTHESIA

    The following is your proposed anesthesia for your dental treatment

    Sedation or General Anesthesia by a Dental Anesthesiologist in an office-based non-hospital environment

     

    IX. ALTERNATIVE OPTIONS


    The following are the alternative options for your dental treatment

    • No dental treatment at all
    • Dental treatment without any Sedation or General Anesthesia (awake)
    • Dental treatment with Minimal Sedation or Moderate Sedation by a dentist in the dental office
    • Dental treatment with any Sedation or General Anesthesia by a different dental anesthesiologist in the dental office
    • Dental treatment with any Sedation or General Anesthesia by a physician anesthesiologist in the dental office
    • Dental treatment with any Sedation or General Anesthesia by a nurse anesthetist (in jurisdictions where they are allowed) in the dental office

    Dental treatment with any Sedation or General Anesthesia by a physician anesthesiologist and/or a nurse anesthetist in the hospital

     

    X. YOUR AUTHORIZATION AND REQUEST

    I hereby authorize and request the dental anesthesiologist, Eric Han DDS and/or Jack Louie DDS to perform the anesthesia 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 by any routes, techniques, or depths (from minimal sedation to general anesthesia) that is deemed suitable by the anesthesiologist. It is the understanding of the undersigned that the anesthesiologist will have full charge of the administration and maintenance of the anesthesia, and that this is an independent function from the surgery/dentistry performed by the dentist. I also understand that the anesthesiologist has no responsibility in the dental treatment to be performed, the diagnosis, or the treatment planning involved. The Dental Anesthesiologist assumes no liability from the surgery/dentistry performed by the dentist while under the anesthesia, and the dentist of the record assumes no liability from the anesthesia services performed by the anesthesiologist. 

    I have been fully advised and completely understand the alternatives to sedation and general anesthesia in a dental office. I understand that I have the right to ask questions, request information, consider any risks, request alternatives treatment options, and request more time to consider my options. I understand that there is no warranty and no guarantee as to any result and/or cure. It is also understood that the anesthesia services are completely independent from the procedure performed by the dentist. I accept the possible risks, side effects, and dangers of the proposed anesthesia. I am satisfied with the information given to me and I consent to the anesthesia in a dental office by a Dental Anesthesiologist.

  • Your appointment will be cancelled. Are you sure?

  • Parent/Guardian Accompany of a Pediatric Patient

    No outside individuals are allowed in the procedure room during anesthesia of a patient, including family members.

    However:

    Parents/Guardians of a pediatric patient may accompany their child during the initial stages of anesthesia, provided that they listen to our five-minute pre-recorded audio entirely, which will be sent to your email address two days before the appointment.

     

    Parents/Guardians who do not wish to participate in this process are not required to listen to the pre-recorded audio. However, they must still acknowledge that you have received and understood our pre-operative instructions, which will sent to you via phone call or a text message one day before the appointment.

  • Only the patient (if 18 or over), or the legal guardian of the patient (if under 18) may sign the informed consent on behalf of the patient.

  • Clear
  • Should be Empty: