Private Pay Packet

CarePoint Anesthesia Grand Rapids Michigan Pediatric Dentists


  • REGISTRATION FORM

  • PATIENT INFORMATION:
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  • RESPONSIBLE PARTY:
  • NPO Guidelines for Anesthesia
    • Nothing to eat after midnight the night before
    • Clear liquids (water, apple juice, Gatorade, or Sprite) can be consumed after midnight, but they must be stopped 4 hours before the appointment time that was provided to you by the dental office
  • I certify that:
    • I have read and understand the fasting guidelines.
    • CarePoint may communicate patient information using the contact information listed above.
  • Date Format: MM slash DD slash YYYY
  • FINANCIAL AGREEMENT

  • Welcome to CarePoint Anesthesia Group of Michigan! ​We are dedicated to providing specialized anesthesia services to the familiar and comfortable environment of your dentist’s office, bringing a tailored and personal touch to your care. We would also like to inform you of your financial obligations. The following is our company’s financial policy:

  • FINANCE POLICY​: Please​ acknowledge ​below that you have read, understood, and acknowledge our financial policy.

  • I certify that I have read, understood, and acknowledge receipt of a copy of the above Financial Policy. I also understand and acknowledge my financial responsibility for the anesthesia services provided by CarePoint Anesthesia Group of Michigan, LLC.

  • Date Format: MM slash DD slash YYYY
  • CREDIT CARD PAYMENT AUTHORIZATION

    By signing below, you authorize CarePoint to submit payment for any remaining balance due on or after the date of service​. Alternatively, card information can be provided through our website in the form of a deposit.

  • MEDICAL HISTORY FOR PEDIATRICS

  • PATIENT INFORMATION:


  • Date Format: MM slash DD slash YYYY

  • PREGNANCY/NEONATAL HISTORY:

  • MEDICAL HISTORY FOR PEDIATRIC (Cont’d)

  • INFANCY/CHILDHOOD/ADOLESCENCE HISTORY:

  • HEART DISEASES:

  • LUNG DISEASES:

  • OTHER CONDITIONS:

  • I certify that the above information is complete and accurate to the best of my knowledge. I understand that providing incomplete or inaccurate information may negatively influence my child’s treatment and treatment results. I also certify that CarePoint may communicate patient information using the contact information listed above.

  • Date Format: MM slash DD slash YYYY
  • CONSENT FOR ANESTHESIA SERVICES

  • The following is provided to inform patients about having treatment under anesthesia. The information is not presented to make you more apprehensive, but rather to enable you to better understand the risks and benefits involved with anesthetic treatments.

    I, the undersigned, hereby authorize and request any doctor represented with CarePoint to administer anesthesia as previously discussed with me. I understand and agree that procedures not talked about, but deemed necessary for my child’s well-being may be performed to supplement the planned anesthesia. It has been explained to me that all types of anesthesia, although safe, involve some risks and no guarantees can be made concerning results. Serious complications are very rare. The following are complications that may be associated with the anesthetic treatment:

  • COMMON COMPLICATIONS:

    • Pain and/or bruising at the IV site
    • Sore throat and/or hoarseness
    • Muscle aches
    • Nausea and/or vomiting

    RARE COMPLICATIONS: :

    • Hearty Injury
    • Brain damage or death
  • UNCOMMON COMPLICATIONS:

    • Headaches
    • Injuries to lips, teeth, mouth or throat from airway instruments or devices
    • Unexpected drug reaction
    • Infection at intravenous site and veins nearby
    • Bleeding/injury in the nose due to passage of a breathing tube
    • Lung infection
    • Eye injury or infection
    • Weakness in breathing after awakening
    • Nerve Damage
    • Alternative options to deep sedation/general anesthesia have been discussed with me and may include the use of local anesthesia with nitrous oxide sedation or local anesthesia alone.
    • I confirm that the patient has not had anything to eat or drink (other than indicated medications with the smallest amount of water) for at least eight (8) hours prior to anesthesia.
    • I certify that to my knowledge that the patient is not pregnant or trying to become pregnant.
    • I have read and agree to the HIPAA Notice of Privacy Practices posted on our website www.cpmich.com.
  • I consent to the anesthesia deemed appropriate by my anesthesiologist. I acknowledge that I have read this form or had it read to me and that I understand the risks, alternatives, and expected results of the anesthetic plan of care.

  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.