Attestation of Anesthesia Information Delivery

Attestation of Anesthesia Information Delivery

For Pediatric Practice ONLY
Please deliver the “Anesthesia Information Disclosure V2026.09” (“Disclosure”) to the patient’s parent or a legal guardian 2-7 days prior to the anesthesia appointment.

This Disclosure is available:
1. PDF below
2. www.thedreampros.com --> "Patient Resources" --> "Anesthesia Information - Pediatric". See screenshot below.
Patient Name

First NameLast Name
Delivered to (check all that apply):

Other legal guardian (describe)
Delivery method
Dental Office Name
Office Staff Name
I attest that I have delivered the above-mentioned Disclosure to the parent/legal guardian of the Patient, and that the parent/legal guardian has affirmed receipt of or access to the Disclosure.
Signature
Should be Empty: