Your child is scheduled for full mouth dental rehabilitation under general anesthesia at Baptist Health Surgery Center – Lexington, KY. It is required that patients undergoing general anesthesia have a pre-surgical physical evaluation within 30 days of their scheduled surgery. You will need to schedule an appointment with your family doctor to complete the “Medical Clearance Form” you received at your child’s recent dental appointment. Anesthesia must have this completed form prior to administering general anesthesia or your child’s surgery will be canceled. In addition, it is extremely important that your child does not have any food or drink including water, after midnight the night before the scheduled surgery. If this is not followed your child’s surgery will be canceled.

Baptist Health Surgery Center will reach out to you 24 hours prior to your child's procedure to go over surgery information and arrival times. You will receive a text message from our office, please disregard this as it’s a placement holder for us. Failure to confirm your child’s procedure appointment may result in cancellation of procedure. If you miss 1 scheduled Dental Surgery (OR) appointment, we will not be able to reschedule your child and any siblings for future appointments with our office.

We look forward to providing you with the best possible service and care. Thank you in advance for your assistance and cooperation in helping us achieve that goal.

Sincerely,
Emilee Sexton, DMD
Mount Sterling Pediatric Dentistry

Baptist Health Surgery Center
3000 Baptist Health Blvd. Suite 110
Lexington, KY 40509

1. The nature and purpose of the operation or procedure, possible alternative methods of treatment, the risks involved and the possibility of complication have all been explained to me. I acknowledge that no guarantees have been made to me concerning the results of the operation or procedure. I understand the nature of the operation or procedure to be: Full Mouth Dental Rehabilitation which may include but are not limited to any of the following procedures: comprehensive oral evaluation, dental x-rays, prophylaxis, crowns (stainless steel, composite, or zirconia), composite restorations, sealants, space maintenance, and primary or permanent teeth extractions which will be performed by or under the direction of Dr. Emilee Sexton, DMD.

2. I consent to the administration of treatment that may be considered necessary or desirable in the judgment of the dentist performing the procedure and I will not be notified of necessary changes or additions to the procedure until after the procedure is completed.

3. I consent to the administration of general anesthesia in order to complete the above named procedure as given by the medical staff of the medical facility.

4. I consent to the disposal by authorities of any tissues or parts which it may be necessary to remove.

5. The risks involved in the performance of the above described procedure include but are not limited to: pain, bleeding, swelling, infection, dry socket, drug reaction, trismus (limited mouth opening), damage to adjacent teeth and/or restorations, tooth lodged into tissue space, root tip fracture, bone or jaw fracture, temporary or permanent numbness or tingling associated with the lower lip and/or tongue, need for additional procedures, sinus exposure, and reaction to local anesthetic. These risks have been explained to me and I understand them fully.

I have read and had explained to me this consent form and I fully understand the contemplated procedure and the risks involved.

We are setting aside 3-4 hours of our time and the hospital anesthesia team’s time to care for your child’s needs. Cancelling or not showing to a Dental Surgery (OR) appointment prevents us from being able to schedule another child who needs an earlier appointment due to pain or infection. Please be respectful of this.

We understand there may be circumstances in which your child will become ill the day of surgery, we just ask that you call our office at (859)274-4434 as soon as possible. We do require a doctor’s excuse for the day the surgery was cancelled before we can reschedule your child’s Dental Surgery (OR) if you cancel due to illness.

If a Dental Surgery (OR) appointment is broken due to no physical in the appropriate timeframe that was given or cancelling or no showing the day of the surgery, the patient and any siblings will be dismissed from our practice.

If the appointment is missed and notification was not given it could result in any or all of the follow:
• If applicable, we will report failed appointments to the Kentucky Department of
Medicaid services which could result in termination of your child’s insurance.
• Prior to rescheduling we will require an outpatient room reservation fee of $100.00 to be paid upfront and this fee is NOT covered by insurance.
• We reserve the right to terminate your child’s care with our office.

We appreciate your cooperation with this policy and value you're understanding as we strive to provide the best quality care for your children.

I understand that my child is going to have his/her dental work completed under general anesthesia at an outpatient facility by Dr. Emilee Sexton. I understand that while today’s exam found it necessary to have my child treated under general anesthesia, the following may apply: limited oral evaluation and/or inability to get diagnostic radiographs, which could contribute to an incomplete treatment plan. I understand that any additional needs my child may have will be addressed during the surgery to avoid a second operating procedure as recommend by the American Academy of Pediatric Dentistry. I am also aware that I will be finally responsible for any changes incurred to my child’s treatment plan.