Request Our Service

Today's Date (DO NOT MODIFY)

MonthDayYear
Hidden and Used for Age Calculation
Placeholder Date and Time (DO NOT MODIFY)

MonthDayYear

Hour MinutesAM/PM Option
A.GAP.GAP.GA-MTIVAOA-SOA-L
Prefill the following phrase into "Form Initiation Source" of the Med History Form
- No Critical Action (default)Cancel CaseClose CaseReschedule
- NoYes - Upload ExistingYes - Completely BypassPartial - Send Consent Only
- NoYes
- NoYes
- NoYes
- Age Category
- Request Our Service
- Region*
- Provider*
- Region*
- Provider*
- READ ONLY: Provider's minimum age for the selected Region
- READ ONLY: Provider's maximum age for the selected Region
- Provider Email
- Office Phone Number*
  Digits only
- Dental Practice Name*
- Dental Practice Email Address*
- Pediatric Dental (has a treating or supervising pediatric dentist)General Dentistry or Other Specialty
- If you need NEW DATES, please contact the provider or our office directly.
  
  Dr. Han: Text him directly at 617-992-0104
  
  Dr. Louie: Contact our office
  
  office@thedreampros.com
- Appointment Date*
  
  MonthDayYear
  If you don't already have a date reserved with us, please contact us first
  Hour MinutesAM/PM Option
- Patient Name*
  
  First NameLast Name
- Patient Date of Birth*
  
  MonthDayYear
- Age
- The patient is currently {age} years old.
  
  This is outside of the the Provider's age requirement of "between {readOnly} and {readOnly442} years of age"
  
  Please select one of the options in the next question.
- We have not yet discussed it with our Anesthesiologist - Please DO NOT proceedYes (Anesthesiologist is aware)Yes (the patient will be within the Provider age limit at the date of the appointment)
- Patient's (or Legal Guardian's) Email Address*
  Please enter a real email address
- Patient's (or Legal Guardian's) Cell Phone Number*
  For Minors, please indicate Parent/Legal Guardian's NumberFormat: (000) 000-0000.
- Read Only: Do conditions require Dental Office to verify fees?
- Comfort (not anxious)Mild AnxietySevere AnxietyGag ReflexUncooperative
- EnglishSpanishPortugueseArabic
- PatientDental Practice
- Self Pay (Private Pay)Dental Office PayMedicaid
- Appointment
  
  MonthDayYear
  
  MinutesAM/PM Option
- Appointment End
  
  MonthDayYear
  
  MinutesAM/PM Option
- Participating Program -3
- Participating Program -2
- Participating Program -1
- Participating Program 1
- Participating Program 2
- Participating Program 3
- Participating Program 4
- Participating Program 5
- Notes when inserting "dates" from a calculation field into a date field.
  
  Do not put 0, as it will default to 11/30/1899.
  
  Numeric value of 1 starts from 1/1/1970 and subsequent integer is an additional day thereafter.
- Effective Date
  
  MonthDayYear
- TDPDental Practice
- Medicaid State/Program*
- Payment
- Medicaid ID*
- Medicaid Copay Deposit Required?
- Medicaid Copay Deposit Amount
- NY
- Provider Credentialed Date Error: Neg means not credentialed yet
- The Provider does not participate in the Medicaid Program you have selected
  
  Please select a different option
  
  Program Selected: {payment}
  
  Provider: {provider}
  
  The Provider participates in the following program(s):
  
  {participatingProgram}
  
  {participatingProgram393}
  
  {participatingProgram394}
  
  {participatingProgram395}
  
  {participatingProgram396}
- Full Case General Anesthesia (typical)Mask Only (see restrictions)
- Only the following procedures may be done under a maskdown general anesthesia:
  - Extraction of primary teeth
  - Frenectomy
  - No-prep crowns
  If definitive airway protection is deemed necessary, a maskdown may be converted to a nasally intubated general anesthesia.
- Procedure*
- Procedure
- 1 Quad2 Quads3 Quads4 Quads
- Anticipated procedure time (in HOURS)*
  Example) 1.25 = 1 hr and 15 mins; 2.75 = 2 hrs and 45 mins
- Duration of Procedure (hours)*
- Involved Number of Quadrants
- Anticipated Duration of Procedure
- Medical Documents (Med Clearance, H&P, etc.)
  
  Cancelof
- Legal Documents (Guardianship papers, Consents, etc.)
  
  Cancelof
- Total Anesthesia Fee [H]
- Buffer [H]
- Estimated Fee Max [H]
- Auto Adjustment [L]
- Total Anesthesia Fee [L]
- Billable $
- Verify Fee
- Fee Collector Email
- Estimated Anesthesia Fee Range
  
  Minimum {totalAnesthesia}
  
  Maximum {estimatedFee433}
- Days Until Appt
- Last Minute Add?
- ATTENTION: The appointment being requested is within 48 hours
  
  For last minute add-on's:
  
  Anesthesiologists are not obligated to accept laste minute add-ons.
  
  Cases may not be reviewed until immediately before the procedure, at which point it may be denied at the Anesthesiologist's discretion.
  
  TDP may not be able to make attempts to reach the patient for paperwork and preop instructions. Dental Clinic requesting the last minute add-on must ensure proper NPO and paperwork completion.
- I agree to the above terms for adding on last minute patientsI do not agree to the above terms for adding on last minute pateints
- Units
- Upload Intraop Records (optional)
  
  Cancelof
- Provide any important information
- Patent Pending. Professional Software Development Anticipated.
  
  - Anesthesia Data Systems Technologies, LLC
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