Sedation Instructions

Initial each section, then sign. A PDF will be generated at checkout.

Patient Information

Patient Name *

Phone Number *

Section 1 of 13 Step 1 of 14

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* Initial Here

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Please complete all fields below, add your signature and witness signature to finalize the form.

Parent/Guardian Name *

Parent/Guardian Date *

* Parent / Guardian Signature

Parent/Guardian signature

Required

Witness Printed Name *

Witness Date *

* Witness Signature

Witness signature

Required