Oral & IV Sedation Patient Drop Off

Oral & IV Sedation Patient Drop Off

DD slash MM slash YYYY
Oral Sedation Guardian Name(Required)
Consent(Required)
Patient Name(Required)
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.
Consent(Required)
Clear Signature

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