Register Patients

Today's Date (DO NOT MODIFY)

MonthDayYear
Hidden 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
- Bypass Intake (default: No)
- Bypass H&P (default: No)
- Bypass Payment (default: No). Will not send payment form to anyone
- Bypass Preop (default: No)
- Register Patients
- Dental Practice Code
  Optional
- Region
- Office Phone Number
  Digits only
- Dental Practice Name
- Dental Practice Email Address
- Dentist Specialty
- Practice Specialty
- Dr. Han's Calendar
  
  What does this calendar do?
  
  It reserves a spot for you and your patient(s)
  
  How do I use this calendar?
  1. Click on the calendar
  2. Select a "Long Day" or a "Short Day"
  3. Find a date that works
  4. Enter your office info
  5. Click "Book"
  What if I already have a date?
  
  You may skip this
  
  I want to send patient info, but I don't have a date yet
  
  You may skip this
  Leave the "Appointment" section BLANK
- Q: Does this calendar reflect the anesthesia provider's availability?
  
  NO. Please make sure you have a date set with the provider before entering the appointment date/time.
  
  Q: What if I don't?
  
  The provider may not be available.
  
  Q: Is this part required?
  
  Yes, except for waitlisted patients.
- Appointment
  
  MonthDayYear
  
  MinutesAM/PM Option
- Appointment End
  
  MonthDayYear
  
  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
- 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.
- Main Reason for Anesthesia (Used for anesthetic planning. You may change the default selection)
- Patient's Preferred Language
- Anesthesia Type
- 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
- Number of Quadrants Involved
- Duration of Procedure (hours)
- Have you requested medical clearance for this patient using our medical clearance form? This form is available on our website at www.thedreampros.com.
- Who should we collect payment from?
- Financial Responsibility
- Anesthesia Fee
- Medicaid State/Program
- Medicaid ID
- Medicaid Copay Deposit Amount
- Verify Fee
- Fee Collector Email
- Medical Documents (Med Clearance, H&P, etc.)
  
  Cancelof
- Legal Documents (Guardianship papers, Consents, etc.)
  
  Cancelof
- 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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