Oral & IV Sedation Patient Drop Off

Today's Date(Required)

Oral Sedation Guardian Name(Required)

First Name Last Name

Patient Name(Required)

First Name Last Name

Release of Patient to Designated Caregiver

I am aware and responsible for the patient who is undergoing sedation for the next 24 hours as the patient in my care.
I am aware that the person in my care will need to drink plenty of fluids, at least 2-3 glasses of water after getting home.
I am aware that the person in my care cannot walk up or down stairs alone until completely recovered from sedation.
I am aware that the person in my care cannot operate a vehicle or hazardous devices, or make any important decisions for the next 24 hours.
I, the understated, understand and agree to follow the list stated above and will not hold Quarry Park Dental liable for the patient after leaving the dental office.

Signature(Required)

Dentistry Made Simple.

Day of the week

Opening Hours

Monday

9 am – 5 pm

Tuesday

9 am – 5 pm

Wednesday

9 am – 7 pm

Thursday

9 am – 7 pm

Friday

8 am – 3 pm

Saturday

9 am – 3 pm

Sunday

10 am – 5 pm