IMPORTANT INSTRUCTIONS REGARDING YOUR ANESTHESIA

You will always be given local anesthesia for your surgery, but you may choose any of those listed below as a supplement.
Each choice requires a different preparation on your part and for your safety it is important that you read and follow the
instructions carefully. If you are unclear about anything, please ask your doctor.
For all surgery, please wear comfortable, loose-fitting clothing. Tops/shirts should have sleeves that are easily drawn up
above the elbow. When possible, colored nail polish should be removed before surgery.
If you are going to use:
A. LOCAL ANESTHESIA
1. Have a light meal a few hours prior to surgery.
2. For more extensive procedures you may wish to have someone drive you home.
3. Plan to rest for a few hours after surgery.
B. ORAL PREMEDICATION
1. Take the medication at the time directed before your surgery.
2. Follow instructions for any additional anesthesia chosen.
C. NITROUS OXIDE
1. You may have a light meal four (4) hours prior to surgery.
2. You must have a responsible person to drive you home after surgery.
3. Plan to rest for the remainder of the day.
D. IV ANESTHESIA OR GENERAL ANESTHESIA
1. Nothing to eat or drink for six (6) hours prior to surgery. However, it is important that you take any
regular medications (high blood pressure, antibiotics, etc.) or any premedication prescription that we may
have provided, using only a small sip of water.
2. You must have a responsible person to accompany you, stay in the office reception area during surgery and
drive you home after the procedure.
3. Plan to rest for the remainder of the day. Do not operate cars, power tools, machinery, etc., for twenty-four
(24) hours after surgery.

OTHER INSTRUCTIONS:
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Our goal is to provide you with a safe, pleasant and effective anesthetic. In order for us to do this it is imperative
that we have your full cooperation. Please feel free to call us with any questions concerning your surgery or
anesthetic.
Insurance companies rarely reimburse the full amount, usually paying between 50% and 80% of the cost. This office
quotes current fees that are within the usual and customary range of oral and maxillofacial surgery offices within our area,
while many companies pay from a set fee schedule that is quite often outdated. We are happy to file insurance claims for
you.
We ask that a partial payment, usually approximating your estimated percentage of the fee, be made at the time of surgery. In
cases of divorced parents, the parent bringing the child will be deemed responsible for payment.
Total fee for surgery $ _________________________________________________________________________
A minimum payment of $ _______________ is expected at the time of surgery.
Appointment: _______________________________ @ _______________________________________am/pm.
**Please arrive 15 minutes prior to your appointed time**