✍️ Anesthesia Consent
✓ Consent Signed
I, the undersigned, authorize the administration of anesthesia and related services by the licensed provider of Mobile Dental Anesthesiology of New York.
I understand the nature of anesthesia, including potential risks such as: nausea, vomiting, sore throat, headache, dizziness, allergic reactions, breathing difficulties, and in rare cases, serious complications.
I confirm that I have disclosed all medical history, medications, allergies, and prior anesthesia experiences. I have had the opportunity to ask questions and have received satisfactory answers.
I consent to the anesthetic procedure described and authorize the provider to take any necessary emergency measures.
Patient Age
Guardian Information
Patient / Guardian Signature
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Patient Signature
Provider Signature
Provider signs here
Provider Signature