marketingbysos.com - ASA Sedation Form

Sedation Referral Checklist
NOTICE: Sedation will NOT be scheduled until all of the Paperwork and Physical are returned.
Send with each Patient referral:

Parent/Office to complete Request for Anesthesia form.Parent/Legal Guardian to complete Authorization to Release formCopy of patient Health History FormCopy of all active Health (Medial) insurance cards front and backProposed Treatment PlanCurrent H&P (Physical) for the patient. (Can't be older then a year from the scheduled date of service.)If Parent/Legal Guardian is not going to be present at appointment, we will need signatures:
Please select

Anesthesia Consent FormFinancial Policy
Fax or securely email items to Little Chompers once all items are completed to Office@littlechomperspd.com or FAX 877-588-7935
Advanced Specialty

ANESTHESIA
Sedation Referral Checklist
To send with each patient referral:

Parent/Office to complete Request for Anesthesia formCopy of all active Medical Insurance cards front and back.Parent/Patient to complete Health History formCopy of Dentist Proposed Treatment PlanCurrent Physical (within 12 months from scheduled appt). If not on file, ASA can help retrieve.
Fax or securely e-mail above completed forms in PDF Format to: referral@asasleep.com Fax: 785-422-5477

Due: 10 business days prior to the scheduled procedure date
ASA Declaration: We will provide safe and high-quality anesthesia care consistently to every patient. Each patient, and person(s) associated with the patient, will receive respect, understanding and compassion prior to, during, and after each anesthetic. Services will be delivered with vigilant adherence to a set of ethical standards focused on the patient and family. ASA will continue to provide and exceed the standard of care required in all aspects and provide a gold standard to the industry.
ADVANCED SPECIALTY ANESTHESIA, LLC

REQUEST FOR ANESTHESIA SERVICES Email to: referral@asasleep.com Fax: 785-422-5477
Referring Provider Office please complete below section:
Referring office/doctor:
Sedation date scheduled or (TBD)To Be Determined

MonthDayYear
Date
Estimated Treatment Time:

1 hr.90 min.2 hr.2 hr. 30 min.Other
*Please provide copy of dental treatment plan in packet.
Patient Information
First Name:
Last Name:
(Nickname):
Date of Birth:

MonthDayYear
Date
Sex

MaleFemale
Preferred Language City:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:
Please enter a valid phone number.
Alternate Phone
Please enter a valid phone number.
Ok to contact by Text message:

YN
Does patient reside in a facility/nursing home?

YesNo
If yes, Name/Phone:
Is the patient in Foster Care?

YesNo
Foster Care Name/Phone:
Parent/Guardian Information (patients 18 years of age or younger)
Name

First NameLast Name
Relationship to Patient:
Home Address (if different from patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email Address:
example@example.com
Medical Insurance Information

Please provide copy of card
Insurance Company:
ID Number
Policyholder's Name:
Policyholder DOB:

MonthDayYear
Date
I hereby give permission to Advanced Specialty Anesthesia, LLC to:

-To leave a message regarding information relevant to anesthesia services.
-Discuss and request necessary medical records from any physician facility named below:
Primary Care Physician:
Hospital/Other:
Patient/Guardian Signature:

Clear
Printed Name:
Date

MonthDayYear
Date
Attach: copy of the medical card, pre-anesthesia health history, and patients current physical

Permission signature by patient/guardian is valid for 1 year from signature date.
Pre-Anesthesia Health History
Patient Name:
DOB

MonthDayYear
Date
Weight
Height
ALLERGIES:

NoneSoyEggsPeanutslodineTree nutsLatex

Please list any additional food and/or Medication allergies:

	Allergy	Reaction
1
2
3

Has the patient been prescribed an EpiPen?

YesNo
CURRENT MEDICATIONS:
Please list ALL medications, supplements, inhalers, and medications through a nebulizer:

None
List
PREVIOUS SURGERIES & PROCEDURES DONE WITH ANESTHESIA

None
List
HOSPITALIZATIONS:

None
List
OTHER MEDICAL INFORMATION:
Is there any Family History of Anesthesia Complications?

YesNo
If yes, please Explain:
Has the patient visited the ER in the last 30 days?

YesNo
If yes, please list reason, date, and at which hospital they were seen:
Primary Care Physician:
Has patient seen specialty provider?

YesNo
Provider Name & Specialty:
Date last seen

MonthDayYear
Date
CARDIAC (HEART)

NoneIrregular HeartbeatHeart MurmurCongenital AbnormalityAbnormal Heart TestsChest pain/PalpitationsHigh Blood PressurePacemakerCoronary Artery DiseaseHeart Attack
Heart Attack - Date of occurrence

MonthDayYear
Date
Heart Attack:

Last Cardiology Visit:Next Required follow up
Last Cardiology Visit:
Next Required follow up in months
STOMACH, LIVER, KIDNEYS None Acid Reflux/GERD

NoneAcid Reflux/GERDChronic Nausea and/or VomitingHiatal HerniaFeeding Tube/PEG tubeHepatitis A, B, or CChronic Kidney DiseaseFatty Liver DiseaseCirrhosis of the LiverOther
Advanced Specialty Anesthesia
NEUROLOGIC (BRAIN)

NoneSeizuresParalysis/Muscle WeaknessHydrocephalusFainting/Dizziness
Date of last seizure

MonthDayYear
Date
ENDOCRINE:

NoneDiabetesThyroid DisorderAdrenal DisorderMetabolic Disorder
Date of last A1C:

MonthDayYear
Date
Result:
PSYCHOSOCIAL:

NoneDevelopmental DelayAutismIntellectual Disability/MRADD/ADHDDepression/Anxiety
PULMONARY (LUNGS)

NoneAsthma/Reactive Airway DiseaseRecent Cold/Respiratory InfectionBronchitis/Pneumonia (last 6 weeks)TuberculosisChronic CoughRSV/CroupCOPD/Emphysema
Tuberculosis

ActiveLatent
GENETIC DISORDERS

NoneAngleman's SyndromeFragile XDown's SyndromeDiGeorge SyndromeWolf-Parkinson-White SyndromeTurner's/Klinefelter Syndrome
EAR, NOSE, THROAT

NoneEnlarged Tonsils/AdenoidsSleep Apnea (pauses or gasps in breathing during sleep)Recent Strep or Throat infectionSnoringDifficulty Swallowing
MUSCULOSKELETAL

NoneNone Cerebral PalsyScoliosisArthritisMuscular DystrophyChronic Headaches/MigrainesOCVA/Stroke/TIA
Date of occurrence

MonthDayYear
Date
BLOOD DISORDERS:

NoneAnemiaBleeding/Clotting Problems (including family history)Easy BruisingSickle CellHIV/AIDSCancer
Cancer: Type
Cancer: Date of Diagnosis:

MonthDayYear
Date
Are there any other diagnoses or pertinent medical information you feel we need to be aware of?

YesNo
If yes explain
I understand that withholding any information about my child's or my health could jeopardize his/her safety. Therefore, I have reviewed the above medical health history carefully and have answered all questions truthfully and to the best of my knowledge. I hereby give permission to Advanced Specialty Anesthesia to discuss and request necessary medical records from any physician/facility named below.
Primary Care Physician:
Specialist:
Hospital/Other:
Parent/Guardian Signature:

Clear
Printed Name:
Date

MonthDayYear
Date
Relationship:
Should be Empty:

Sedation Referral Checklist

Advanced Specialty

Sedation Referral Checklist

ADVANCED SPECIALTY ANESTHESIA, LLC

Referring Provider Office please complete below section:

Patient Information

Parent/Guardian Information (patients 18 years of age or younger)

Medical Insurance Information

Pre-Anesthesia Health History

CURRENT MEDICATIONS:

OTHER MEDICAL INFORMATION:

Advanced Specialty Anesthesia