DAVID A. GUTZMAN, DDS

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DENTAL ANESTHESIOLOGY PO BOX 1058 DRAPER, UT 84020 (801) 571-5665 FAX (801)572-9491

COMPLETE AND SIGN THIS PAPERWORK ~ THEN SEND BY CLICKING THE SUBMIT BUTTON AT THE BOTTOM OF PAGE TWO. DISCLAIMER: IF EMAILING THIS FORM RATHER THAN SUBMITTING THROUGH THE SITE, EMAIL WILL BE UNENCRYPTED.

Patient Birthdate

Referral Dentist

Person Responsible For Account:

Name

Street Address

City State Zip Phone#

Birthdate Employer Bus Phone#

If guardian, relationship to patient

In Case of Emergency; Closest Relative Not Living With You:

Name Phone#

A $100 nonrefundable deposit is required to schedule your anesthesia appointment. The

deposit is applied to the anesthesia fee the day of service. The deposit can be paid with

credit card over the phone.

THE REMAINING BALANCE IS DUE THE DAY OF SERVICE.

Payment can be made with cash, money order, or credit card. Credit cards accepted: Visa,

Discover, MasterCard, and American Express.

NO CHECKS ACCEPTED!

We accept Care Credit with “No interest” payment plans - available upon approved credit.

To apply go to care credit.com

Insurance Info: We will provide you with an insurance form the day of service. You will need

to sign and date it, and submit it to your insurance company. Any reimbursement should go

directly to you.

Typing your name below indicates that you understand, agree with, and give permission to

the above policies, and that you have answered all the information contained herein truthfully.

Signature Date

patient/parent/spouse/guardian

DAVID A. GUTZMAN, DDS

gutzmanoffice@gmail.com

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DENTAL ANESTHESIOLOGY PO BOX 1058 DRAPER, UT 84020 (801) 571-5665 FAX (801)572-9491

Patient’s name

Male Female Weight lbs Height ft' in"

Answer each of the following questions (this information is confidential):

YES NO Are you under the care of a physician? If yes, who:

YES NO Currently taking any medications? If yes LIST:

YES NO Any drug allergies/sensitivities? If yes LIST:

YES NO Hospitalized in past 5 years? If yes LIST:

YES NO Have you ever had anesthesia for surgery? If yes LIST:

Check any of the following which you have had in the past or have presently:

YES NO Any mental or physical disabilities?

If yes LIST:

YES NO Do you Snore?

YES NO Do you have Sleep Apnea ?

YES NO Do you use a CPAP/BiPAP machine?

YES NO Do you wear contacts?

YES NO If yes - Do you take naps or sleep with them in?

YES NO Are you very anxious/nervous about dental treatment?

YES NO WOMEN: Are you pregnant?

YES NO Are you nursing?

SIGNATURE Date

patient/parent/spouse/guardian

Dentist Anesthesiologist

Consent for Anesthesia

I hereby consent to, and request David A. Gutzman, DDS to perform the anesthesia technique explained to me, and any

other procedure deemed necessary, or advisable relative to the planned anesthesia. It is the understanding of the

undersigned that Dr Gutzman will have full charge of the administration, and maintenance of the anesthesia, and that this

is an independent function from the surgery/dentistry. Anesthesia provided will either be intramuscular (IM) and/or

intravenously (IV), orally (premedication) or local anesthesia, and by inhalation (nasally - Nitrous Oxide and Oxygen).

Dr Gutzman practices dental anesthesiology with a Class IV anesthesia permit issued by the State of Utah. Monitoring during

the anesthetic will include automatic blood pressure cuff, EKG (heart), pulse oximeter (blood oxygen levels), capnography

(CO2 levels), temperature, precordial stethoscope, and observation.

I have been informed and understand that occasionally complications of the drugs and anesthesia occur, including, but

not limited to: tenderness, bruising, nausea, vomiting, swelling, bleeding, infection, numbness, allergic reaction, stroke, and

heart attack. Some of these complications may require hospitalization and may even result in death.

Severe complications are rare.

WOMEN: I understand that anesthetics, medications, and drugs may be harmful to the unborn child, and may cause birth

defects or spontaneous abortion (miscarriage), and I accept full responsibility for informing the anesthesiologist of a

suspected or confirmed pregnancy.

I have had an opportunity to ask questions relative to my specific treatment, and had them answered to my satisfaction.

I understand for the safety and protection of the patient that no family or friends are allowed in the operatory during the

surgery.

I understand that this is not a release of liability form, but a consent to receive anesthesia, understanding that there are risks

involved. I acknowledge the receipt of and understand both the preoperative and postoperative anesthesia instructions.

SIGNATURE Date

patient/parent/spouse/guardian

Dentist Anesthesiologist

DAVID A. GUTZMAN, DDS

gutzmanoffice@gmail.com

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DENTAL ANESTHESIOLOGY PO BOX 1058 DRAPER, UT 84020 (801) 571-5665 FAX (801)572-9491

Instructions For patients Prior To Anesthesia

Eating and Drinking:

Morning Appointment - NO food after midnight, clear liquids are

fine up to 2 hours before appointment time

Afternoon Appointment - A light breakfast is fine - carbohydrates only

(cereal, toast, oatmeal) - no protein (no eggs, bacon, meats), must be

finished by 6 hours before appointment time.

Clear liquids are fine up to 2 hours before appointment time.

Medications:

Discuss with Dr Gutzman which of your normal medications to take

the day of the appointment.

Change of Health:

A change in health can affect the anesthesia, please call us as

soon as possible to evaluate.

Clothing:

Wear comfortable, loose fitting clothes. Short sleeves please.

Arriving:

A responsible adult must drive you to the appointment.

Instructions For Patients Following Anesthesia

Returning Home:

The patient must be accompanied by a responsible adult at the

time of discharge. Postoperatively the patient cannot drive, take

a bus, or a taxi to return home. Patient cannot drive for 24 hours.

Pain Management:

Sensitivity, tenderness, or pain in the mouth can be expected after

the treatment. Your dentist will prescribe any needed pain meds.

Tenderness or bruising at the IM/IV site is possible, and if uncom-

fortable can be treated with applying warm moist heat to the site,

and taking Ibuprofen. Take pain meds with food in the stomach.

Eating and Drinking:

Eating and drinking may be attempted whenever the patient desires

(asks for). Start out easy with small amounts of clear liquids,

and then soft foods when ready. No alcohol for 24 hours after anesthesia.

Nausea and Vomiting:

Some nausea or vomiting can occur postoperatively. The most common

cause is movement while the patient is still dizzy (like motion sickness). Try

to limit the patient’s movement until the dizziness is gone. Eating too much

food, too soon, can upset the patients stomach also. Swallowing blood

and pain pills on an empty stomach will cause nausea/vomiting.

Activity:

After returning home the patient should rest for the first day and be

attended by someone responsible. Keep the patient’s head propped up

on a pillow, and remove any gauze packs upon returning home.

If you have any questions or concerns call Dr. Gutzman (801) 571-5665