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Dr. Jagatjit Dhillon
Dr. Amardeep Gill
Dr. Do Sung
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Who We Are
Our Clinic
Our Team
Dr. Jagatjit Dhillon
Dr. Amardeep Gill
Dr. Do Sung
Our Forms
New Patient Form
X-Ray Release Form
How We Can Help?
Maintaining A Healthy Smile
How Can I Sleep Better?
Fill Your Cavities
Replacing Missing Teeth
Children’s Dentistry
Restoring your smile
Protect Cracked Teeth
Control Gum Disease
Straighten Your Crooked Teeth
Services We Provide
Orthodontics
Invisalign
Braces
Myobrace
30 Second Smile Test
General Dentistry
Exam
Hygiene
Fillings
TMJ Treatment
Patient Scanning
Teeth Whitening
Emergency Dentistry
Dental Hygiene
Periodontal Health
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Sedation Patient Drop-off Form
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Oral & IV Sedation Patient Drop Off
Today's Date
*
DD slash MM slash YYYY
Oral Sedation Guardian Name
*
First Name
Last Name
Consent
*
I am the responsible (18 years and over) person who is dropping off the patient.
Patient Name
*
First Name
Last Name
Release of Patient to Designated Caregiver
I am aware and responsible for the patient who is undergoing sedation for the next 24 hours as the patient in my care.
I am aware that the person in my care will need to drink plenty of fluids, at least 2-3 glasses of water after getting home.
I am aware that the person in my care cannot walk up or down stairs alone until completely recovered from sedation.
I am aware that the person in my care cannot operate a vehicle or hazardous devices, or make any important decisions for the next 24 hours.
I, the understated, understand and agree to follow the list stated above and will not hold Dental Now Panorama liable for the patient after leaving the dental office.
Consent
*
I certify that I have read and fully understand this consent and release, and that all questions pertaining to this consent have been answered to my satisfaction.
Signature
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