Register Patients

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
Anesth Plan
Prefill the following phrase into "Form Initiation Source" of the Med History Form
- 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)
- Age Category
- Register Patients
- 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
- Practice Specialty
- Click on the calendar below to view the provider's availability. This is to reserve ("book") an available time slot, so that it's blocked out for your patient(s). Do this before entering a date and time on the "Appointment" section below, if you haven't already. (Exception: waitlisted patients)
  
  Dr. Han's Calendar
  
  For Dr. Louie's Availabilties, please contact the office directly (office@thedreampros.com)
- Please be sure to reserve (book) an available date on the provider's calendar above BEFORE entering an appointment date for this patient. Otherwise, the appointment date you request may NOT be available. (Exception: waitlisted patients)
- Appointment
  
  MonthDayYear
  
  MinutesAM/PM Option
- Appointment End
  
  MonthDayYear
  
  MinutesAM/PM Option
- Appointment Date (obsolete field)
  
  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.
- 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.
- Read Only: Do conditions require Dental Office to verify fees?
- Main Reason for Anesthesia (Used for anesthetic planning. You may change the default selection)
- Patient's Preferred Language
- Who will be financially responsible for the anesthesia fees?
- Financial Responsibility
- Have you requested medical clearance for this patient using our medical clearance form? This form is available on our website at www.thedreampros.com.
- 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
- Medicaid Biller for Condition (default TDP)
- Medicaid State/Program
- Payment
- Medicaid ID
- Medicaid Copay Deposit Required?
- Medicaid Copay Deposit Amount
- Non Participating Provider
- 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}
- 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
- Procedure
- Number of Quadrants Involved
- 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.
- Last Minute Case Add-On Terms
- 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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