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Our Office
Our Team
Dr. Jeff Bullock
Dr. Do Hyun Sung
Services
General Dentistry
Exam
Hygiene
Fillings
Sedation Dentistry
Extractions
Root Canal
TMJ Treatment
Teeth Whitening
Restorative Dentistry
Veneers
Crowns
Bridges
Implants
Children’s Dentistry
Periodontal Health
Emergency Dentistry
Orthodontics
30 Second Smile Test
Braces
Invisalign
Invisalign vs Braces
Calgary Ortho Costs
Contact Us
Our Nearby Location
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New Patient Form
X-Ray Release Form
Book Now
About
Our Office
Our Team
Dr. Jeff Bullock
Dr. Do Hyun Sung
Services
General Dentistry
Exam
Hygiene
Fillings
Sedation Dentistry
Extractions
Root Canal
TMJ Treatment
Teeth Whitening
Restorative Dentistry
Veneers
Crowns
Bridges
Implants
Children’s Dentistry
Periodontal Health
Emergency Dentistry
Orthodontics
30 Second Smile Test
Braces
Invisalign
Invisalign vs Braces
Calgary Ortho Costs
Contact Us
Our Nearby Location
Our Forms
New Patient Form
X-Ray Release Form
Book Now
About
Our Office
Our Team
Dr. Jeff Bullock
Dr. Do Hyun Sung
Services
General Dentistry
Exam
Hygiene
Fillings
Sedation Dentistry
Extractions
Root Canal
TMJ Treatment
Teeth Whitening
Restorative Dentistry
Veneers
Crowns
Bridges
Implants
Children’s Dentistry
Periodontal Health
Emergency Dentistry
Orthodontics
30 Second Smile Test
Braces
Invisalign
Invisalign vs Braces
Calgary Ortho Costs
Contact Us
Our Nearby Location
Our Forms
New Patient Form
X-Ray Release Form
Book Now
About
Our Office
Our Team
Dr. Jeff Bullock
Dr. Do Hyun Sung
Services
General Dentistry
Exam
Hygiene
Fillings
Sedation Dentistry
Extractions
Root Canal
TMJ Treatment
Teeth Whitening
Restorative Dentistry
Veneers
Crowns
Bridges
Implants
Children’s Dentistry
Periodontal Health
Emergency Dentistry
Orthodontics
30 Second Smile Test
Braces
Invisalign
Invisalign vs Braces
Calgary Ortho Costs
Contact Us
Our Nearby Location
Our Forms
New Patient Form
X-Ray Release Form
Book Now
Oral & IV Patient Drop Off Form
Oral & IV Sedation Patient Drop Off
Today's Date
*
DD slash MM slash YYYY
Oral Sedation Guardian Name
*
First Name
Last Name
Consent
*
I am the responsible (18 years and over) person who is dropping off the patient.
Patient Name
*
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 Parkway Smiles Dental liable for the patient after leaving the dental office.
Consent
*
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
*
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