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*

Oral & IV Sedation Patient Drop Off