Register Patients

Today's Date (DO NOT MODIFY)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearHidden and Used for Age Calculation
Prefill the following phrase into "Form Initiation Source" of the Med History Form
Provider
Provider Email
READ ONLY: Minimum Age
READ ONLY: Maximum Age
Critical Actions
Skip Registration Notification
- Register Patients
  
  For NON-PEDIATRIC dental practices
- Region
- Office Phone Number
  Digits only
- Dental Practice Name
- Dental Practice Email Address
- Please make sure that you have a date reserved with the anesthesiologist before you continue this section. www.thedreampros.com --> "Provider Availability"
- Appointment
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
  MinutesAM/PM Option
- Appointment End
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
  MinutesAM/PM Option
- Days Until Appt
- Last Minute Add?
- The appointment is within 48 hours
  - Please ensure that your patients complete our paperwork IMMEDIATELY
  - Last minute cases may not be reviewed in time
  - Please be sure to provide appropriate preoperative instructions (no food or drink after midnight of the day of the procedure
- Last Minute Case Add-On Terms
- Patient Name
  
  First NameLast Name
- Patient Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit year
- 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.
- Is the Anesthesiologist okay with seeing this patient, despite his/her age?
- 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.
- Anyone undergoing General Anesthesia (with or without intubation) are REQUIRED to obtain either:
  
  1. Medical Clearance (click on the link to download), or
  
  2. A copy of their recent physical check up summary note
  
  If you anticipate that the patient may need general anesthesia, please advise the patient to obtain one of the two above.
  
  Without one, the patient will only be sedated up to either a moderate sedation or deep sedation, upon the discretion of the anesthesiologist
- Procedure
- Number of Quadrants Involved
- Duration of Procedure (hours)
  Example: 2 hours and 15 mins would be 2.25
- Financial Responsibility
- Anesthesia Fee
- Medical Documents (Med Clearance, H&P, etc.)
  
  Cancelof
- Units
Should be Empty: