IV Sedation - Batavia | Blue Ash

This entire paperwork process takes and estimated 15 minutes and all stages must be completed prior to being scheduled for an appointment.

(section estimate: 2 minutes to complete)
BEFORE we take your time with more detailed paperwork, answer these few questions to ensure IV Sedation is a good fit for your needs/situation.

Validation Question 1 of 7: Dr. Moorehead and Dr. George do extractions only with IV conscious sedation, which is limited to patients 13 years of age or older. We do this because it is safer and more pleasant for the patient as opposed to only local anesthetic (numbing).

I understand this statement and I still wish to continue... Yes No

Validation Question 2 of 7: Dr. Moorehead and Dr. George are General Dentists, experienced with extractions, but not Oral Surgeons. We treat most conditions but we do refer out to Oral Surgeons for more complicated procedures. Dr. Moorehead or Dr. George will review your X-Ray to determine the complexity and will let you know if you need to be referred to an Oral Surgeon.

I understand this statement and I still wish to continue... Yes No

Validation Question 3 of 7: IV conscious sedation is not the same as being “put to sleep” or the same as general anesthesia. It is a twilight sedation with the effect of little to no memory of the procedure. There will still be injections with local anesthesia, but you usually won’t remember that part. IV conscious sedation often cannot help an uncooperative patient.

(If you need a further clarification of what to expect, find someone who has had a colonoscopy and ask them their experience because we use the same methods for sedation.)

I understand this statement and I still wish to continue... Yes No

The next verification deals with whether you will be using dental insurance.

Select if/what type of dental insurance you plan to use for your procedure(s)

Validation Question 4 of 7: Medicaid, as well as traditional insurances, typically do not cover IV conscious sedation except for some wisdom teeth procedures. We will prior authorize the procedure for you to determine the coverage. If the insurance does not authorize, the fee for the sedation service will be $363.09 (this is discounted from our normal fee of $796) which will need to be paid prior to the appointment being scheduled with us.

I understand this statement and I still wish to continue... Yes No

Validation Question 4 of 7: Dental insurance typically does not cover IV conscious sedation except for some wisdom teeth procedures. For those with insurance, we will prior authorize the procedure for you to determine the coverage. If the insurance does not authorize, the fee for the sedation service (only referencing the sedation portion) will be $796 which will need to be paid or included in a signed financial plan prior to the appointment being scheduled with us.

I understand this statement and I still wish to continue... Yes No

Validation Question 5 of 7: If you do not wish to have IV Sedation or do not wish to pay the fees for sedation (if insurance denies them), the good news is there are several other options for you other than Dr. Moorehead and Dr. George. If the procedure is relatively simple, Dr. Piner at Moorehead Family Dentistry in Lebanon will likely be able to treat you. If more complex, you can try another office (as of 1/8/2021) Dr. Josh Atkin at Dayton Dental Unlimited could help or UC Oral and Maxillofacial Surgery.

I understand this statement and I still wish to continue... Yes No

Validation Question 6 of 7: I also realize that my procedure will not be scheduled until all office paperwork is completed AND the sedation fee is paid or the insurance approves the sedation procedure.

I understand this statement and I still wish to continue... Yes No

Validation Question 7 of 7: I realize that if I do not show up for my appointment or cancel within 2 business days, I will not have the opportunity to reschedule and will have to seek treatment elsewhere. Any prepayments for that appointment will be refunded.

I understand this statement and I still wish to continue... Yes No

(section estimate 3 minutes to complete)
Fill out this basic info about you before we direct you to the new patient paperwork. This form AND the paperwork following this page are REQUIRED for us to be able to move forward. If both are not filled out, we are unable to move forward with your appointment. Call us with any questions/concerns.

Patient Info

Patient First and Last Name

Cell Phone Number

Email Address

Age

Health Snapshot

What is your height?

Current weight (if rounding, round only to nearest 10 lbs)

Can you walk up single flight of stairs without assistance and without being out of breath? Yes No

Are you currently pregnant? Yes No

Have you had previous difficulty with having an IV started/finding a vein? Yes No

Are you on a medication called Coumadin or Warfarin? Yes, Coumadin only Yes, Warfarin only Yes, Coumadin and Warfarin No, neither

Are you diabetic? Yes, Type 1 Yes, Type 2 No

** For those with diabetes, eat a small meal (as opposed to fasting entirely) before your sedation appointment and please bring your glucose meter to get a reading before sedation. Thank you! **

Do you have an allergy to any medications? Yes No

Which medications are you allergic to?

Do you currently have any swelling inside or outside of your mouth? Yes No

Are you currently taking antibiotics to help the issue you're being referred to us to resolve? Yes No

What is your current pain level with your dental issue (1-low, 10-high)? 1 2 3 4 5 6 7 8 9 10 No Pain

What is your current anxiety level as you think about resolving your dental issue (1-low, 10-high)? 1 2 3 4 5 6 7 8 9 10 No Anxiety

Referral Information

At which location do you prefer to be seen?

Location

Would you be willing to travel to another location (this often allows you to be seen days or weeks sooner!)? Yes No

If you plan for us to remove your remaining teeth, do you have another dental office planning to make dentures for you? Yes No Does not apply to me

Do you have your referral slip? Yes The office sent you the referral slip No (lost it, etc.)

Referral slip picture upload

A referral slip is required to be seen for IV Sedation and extractions with Medicaid. Please contact your referring office to pick up a copy of your referral or have them electronically send a copy to our office.
If you don't know where to get a referral, check with your dental insurance company's provider list in the area and ask them if they can refer to us. Our referral network is changing so frequently that we are unable to provide a list of offices for you to see, our apologies.

Because the referral slip is required for this online consultation, we recommend you reach out to the referring office to ensure that they've sent over the referral slip.
You can continue to fill out this form, but know that if we don't receive the referral and x-ray, your submission will be considered incomplete and you will need to schedule an in-person consultation to bring those documents to us.

Do you have your x-ray? Yes The office sent you the xray No (lost it, etc.)

X-Ray upload

An x-ray is required to be seen for IV Sedation and extractions with Medicaid. Please contact your referring office to pick up a copy of your x-ray or have them electronically send a copy to our office.
You can continue to fill out this form, but know that if we don't receive the referral and x-ray, your submission will be considered incomplete and you will need to schedule an in-person consultation to bring those documents to us.

Referring Office Name

Driver's License Image

This ID is of the: The Patient The Parent or Guardian

I understand that the Batavia and Blue Ash offices are not handicap accessible and includes stairs to enter.

I understand that I will need to bring a driver to my sedation appointment that will stay in the waiting room during my appointment and drive me home.

I understand that I cannot eat or drink 6 hours prior to the sedation, with the exception of what is needed to take prescription medications of if diabetic (small meal prior to appointment is fine for diabetics). I will take any medications prior to the sedation that were prescribed for the procedure. I will wear a shirt that provides access to my arms such as a t-shirt.

I understand that I need to hydrate that day BEFORE my sedation and take any medications prescribed leading up to the sedation.

In addition to uploading the images above, I will bring my referral slip and xray to my appointment

Questions or Concerns about Procedure(s)

Verify Submission