Phone (650) 282-4171

Fax (650) 282-4187

info@bayanesthesiagroup.com

www.bayanesthesiagroup.com

Instructions and Guidelines for Adult Patients

Please read the following instructions regarding your anesthesia care. Careful adherence to these instructions will allow us to provide the safest care possible.

Required Steps

1. Fill out the Health History Questionnaire. This information allows us to develop a plan that is most appropriate for your needs. Even if you still have questions regarding anesthesia, we will be able to better answer your questions with this information completed. You should receive an email invitation from OnPatient to fill out the forms. Alternatively, the forms can be found under the 'Payments and Forms' tab on our website. They can be returned to your dental office or directly to our office by one of the following ways: email: info@bayanesthesiagroup.com, fax: (650) 282-4187 or clear photos texted to (650) 282-4171.

2. Review the Consent for Treatment. This will be signed electronically via OnPatient, or you may choose to sign on the day of treatment.

3. Complete the Check-In Process. After you have completed the required Health Forms & Deposit, our office will review your health history and clear you for anesthesia. We will then reach out to you by text with all pre-op instructions and eating and drinking guidelines for the day of your procedure. It is IMPERATIVE that you read these messages thoroughly and respond as requested. You will then have an option to receive a phone call from our care team to answer any remaining questions or discuss the anesthesia process in further detail, if you wish. Your check-in process should be completed a minimum of 7 days prior to the day of treatment to ensure your safety. If you have not received a text or call from our office within two business days of setting up your appointment at your dental office, please contact us directly at (650) 282-4171.

Financial information

A non-refundable $500 deposit is due at the time of scheduling. This will secure your scheduled appointment. Your deposit may be completed on our website at: https://bayanesthesiagroup.com Anesthesia fees are due IN FULL on the day of the procedure, and will be automatically charged to this same card, unless prior arrangements are made. By signing this document, you authorize Bay Anesthesia to submit payment to your credit card for any remaining balance due on or after the date of service, until the balance is paid in full. Please contact our office if you wish for an estimate of anesthesia fees.

• Bay Anesthesia Group is a PRIVATE, FEE FOR SERVICE practice and does NOT accept insurance. Upon request, we can provide you with an itemized receipt and a copy of the anesthesia

Phone (650) 282-4171

Fax (650) 282-4187

info@bayanesthesiagroup.com

www.bayanesthesiagroup.com

• record, from the day of treatment, that you may submit directly to your insurance company for potential Out of Network reimbursement. We do not guarantee that you will receive reimbursement from your insurance company. Please contact your carrier directly, for any questions regarding your coverage, their payment policies, and reimbursement procedures.
• I attest that I am not a TriCare patient or TriCare beneficiary.
• Generally, the anesthesiologist will require up to an additional 15 minutes before the dentist can begin treatment and up to an additional 15-20 minutes after the dentist completes treatment. When estimating your anesthesia cost, be sure to account for this anesthesia time in conjunction with the dental time. Anesthesia rates will be reviewed during your pre-operative call or you may request a breakdown of the rates by email.

Other important information 

Please read the attached Pre-Anesthesia Instruction form and follow the instructions explicitly. Violation of any of these instructions or other specific instructions from your anesthesiologist may result in the cancellation of your appointment and forfeiture of your deposit.

Please arrive promptly the day of your procedure. We will be conducting a thorough physical examination and it is important we have enough time to complete this preanesthetic examination. Late arrivals are subject to rescheduling of the procedure, and may result in the forfeiture of your deposit.

Additional payment policies can be found on our website at https://www.bayanesthesiagroup.com/.

Phone (650) 282-4171

Fax (650) 282-4187

info@bayanesthesiagroup.com

www.bayanesthesiagroup.com

PRE-ANESTHESIA INSTRUCTIONS FOR ADULT PATIENTS

We are here to provide a comfortable experience before, during and after your treatment. These instructions are designed with your safety and wellbeing in mind. Neglecting any of the following may lead to your case being postponed. Please do not hesitate to contact us with any questions or concerns you may have.

9 or More Hours Before the Procedure

Your last meal must be completed at LEAST 9 hours prior to your appointment. For most patients, this meal is dinner. Any dinner foods you would normally enjoy are permitted. Examples would be: meat, eggs, bread and pasta.

7 or More Hours Before Procedure:

A Light Meal is permitted but may ONLY include the following: Fruits, vegetables, apple sauce, yogurt, milk, oatmeal, cereal, toast, clear broth and plain rice.

2 or More Hours Before Procedure:

CLEAR FLUIDS and Approved Medications are permitted. ONLY the following fluids are permitted: Water, black coffee (NO creamer or sugar), apple juice, 7up/Sprite, Ginger Ale, Gatorade or Pedialyte. NO MILK. Light Colored Jell-O and Otter Pops are also permitted (*Nothing RED in color please).

 **if your appointment is scheduled in the Afternoon or Early Evening: We highly encourage you to hydrate with Clear Fluids or Jell-O up to 2 hours before the procedure time!

** PLEASE ALSO REFER TO THE EATING & DRINKING GUIDELINES BEFORE ANESTHESIA FOR DETAILED INFORMATION**

Escort: All sedation and anesthesia patients must be accompanied to and from the appointment by a responsible adult. The responsible adult should remain in the office during the appointment unless authorized by the practitioner. For the safety of the patient, the responsible adult must remain in the designated waiting area during treatment time. Office staff will escort the responsible adult back to the treatment area once the anesthesiologist deems it is safe, to be present for recovery. Upon release, the patient must be driven home by the responsible adult (public transportation or cabs are not acceptable.

Clothing and makeup: Casual and comfortable clothing, with short sleeves, and in two pieces, is recommended for easier and more effective placement of monitors. Contact lenses must be removed before the appointment. Facial piercings should also be removed prior to the surgery. Do not wear fingernail polish or use moisturizer on your trunk and arms on the day of the appointment.

Change in health: A change in your health, especially the development of a cold or fever, is very important. For your safety, you may be re-appointed for another day. Please inform the doctor of any change in your health prior to your appointment.

After surgery and anesthesia, please be prepared to have a responsible adult caregiver for the remainder of the day. Rest at home and avoid driving, hazardous tasks, making any important decisions, and working for at least 24 hours.

Phone (650) 282-4171

Fax (650) 282-4187

info@bayanesthesiagroup.com

www.bayanesthesiagroup.com

POST OPERATIVE INSTRUCTIONS FOR ADULT PATIENTS UNDERGOING GENERAL ANESTHESIA

You have just undergone IV sedation/general anesthesia in addition to dental procedures today. Please read and follow these instructions to ease your recovery following dental treatment.

1. A responsible adult should drive you home and remain with you, under direct supervision, until you are fully alert.

2. It is normal to feel tired, forgetful, and groggy after anesthesia. Your judgment and mental acuity will be impaired. It is imperative that you do not drive a car or operate machinery while recovering from anesthesia, nor should you attempt to perform any strenuous work or activity. Relax for the remainder of the day.

3. After surgery, you may experience minor discomfort throughout the day. You may have bruising and tenderness at the site of the IV, or a scratchy throat. This is short-lived and should not cause alarm.

4. The local anesthesia (numbing medication) administered during your surgery normally lasts for 4-6 hours, and it is important to take measures to control the discomfort before it wears off.

5. Nausea and vomiting are common after surgery. To minimize symptoms, lie down, avoid dairy products, take narcotic medications (if prescribed) with small amounts of food, and drink clear liquids until resolution occurs.

6. Your diet should include clear liquids only for the first several hours after surgery (water, apple juice, ginger ale, Gatorade, etc). Fluids are important to prevent dehydration. Your first meal should include soft foods (soup, Jell-o, mashed potatoes, etc). in moderate quantities. Once this is tolerated, you may gradually advance your diet to solid foods. If you are diabetic, maintain your normal diet as much as possible, and follow your doctor's instructions regarding your insulin schedule.

7. Do not drink any alcoholic beverages for the remainder of the day.

Please call our office immediately at (650) 282-4171 if you develop any unexpected reactions. Call your anesthesiologistif your IV site becomes red and tender, if vomiting persists beyond 4 hours, if you develop a fever beyond 24 hours, or if any other matter related to your anesthesia causes concern.

Your doctor's 24 hour number is listed below. Do not hesitate to call if you have any questions regarding the safety of your child.

Bay Area/Northern California:

Dr. Philip Yen (408) 823-0944

Dr. Andrew Young (909) 538-9101

Dr. Ryan Cheung (415) 812-0503

Dr. Janice Huang (909) 851-2927

Dr. Arielle Freed (626) 696-9973

Dr. MC Ho (412) 927-7937

Dr. Goutam Krish (805) 791-1454

Los Angeles/Southern California:

Dr. Michael Alanes (323) 553-0055

Dr. Philip Yen (408) 823-0944

Dr. Andrew Young (909) 538-9101

Phone (650) 282-4171

Fax (650) 282-4187

info@bayanesthesiagroup.com

www.bayanesthesiagroup.com

Confirmation of Receipt of Pre-Operative Instructions and Guidelines

I have thoroughly read the above pre-operative instructions, including the food and drink guidelines that must be adhered to in order to be seen on my scheduled day of treatment. I understand that these guidelines are imperative to my safety, and should they not be followed explicitly, Bay Anesthesia reserves the right to refuse anesthesia treatment and withhold my paid deposit. I further understand that arriving after my scheduled procedure time may result in the cancellation or rescheduling of the appointment, and may result in the forfeiture of my paid deposit.

Lastly, I understand anesthesia fees are DUE IN FULL on the day of the procedure, and will be automatically charged to the same card used for my deposit, unless prior arrangements are made. I authorize Bay Anesthesia to submit payment to my credit card for any remaining balance due on or after the date of service, until the balance is paid in full. An estimate of anesthesia fees is available upon my request.

Should I have any additional questions regarding these policies, I will contact Bay Anesthesia Group directly at (650) 282-4171.