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About Us
Dr. Amardeep Gill
Dr. Arman Sonuhi
Dr. Kirpaul Chattha
Our Services
Cosmetic Dentistry
Restorations
Gum & Bone Grafting
Periodontics
Dental Exams & Cleanings
Oral Cancer Exam
Pediatric Dentistry
Cleanings Prevention
Dental Anxiety And Fear
Dental X-Rays
Tooth Extractions
Wisdom Tooth Extraction
Dental Emergencies
Root Canal Therapy
Invisalign
Office Forms
New Patient Form
X-Ray Release Form
Contact Us
About Us
Dr. Amardeep Gill
Dr. Arman Sonuhi
Dr. Kirpaul Chattha
Our Services
Cosmetic Dentistry
Restorations
Gum & Bone Grafting
Periodontics
Dental Exams & Cleanings
Oral Cancer Exam
Pediatric Dentistry
Cleanings Prevention
Dental Anxiety And Fear
Dental X-Rays
Tooth Extractions
Wisdom Tooth Extraction
Dental Emergencies
Root Canal Therapy
Invisalign
Office Forms
New Patient Form
X-Ray Release Form
Contact Us
Book Now
Oral & IV Sedation Patient Drop Off
Oral & IV Sedation Patient Drop Off
Today's Date
(Required)
DD slash MM slash YYYY
Oral Sedation Guardian Name
(Required)
First Name
Last Name
Consent
(Required)
I am the responsible (18 years and over) person who is dropping off the patient.
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.
Consent
(Required)
I certify that I have read and fully understand this consent and release, and that all questions pertaining to this consent have been answered to my satisfaction.
Signature
(Required)
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