Oral & IV Patient Drop Off Form

  • Oral & IV Sedation Patient Drop Off

  • DD slash MM slash YYYY
  • 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.

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