Forms for Parents

The staff at Minnesota Dental Anesthesia is committed to providing the very best quality care for all patients. To do this, we require certain background health information be provided and for your primary care physician to conduct a history and physical exam for each child who will undergo sedation.

Note: Before Minnesota Dental Anesthesia can treat any patient, the Pre-Operative History and Physical form and HIPPA Release form below must be signed and returned to us via email or fax. Note: We must receive these forms no later than one week prior to the scheduled procedure.

email: info@minnesotada.com
fax: 1-952-487-2638

The Consent for Anesthesia form below can be signed on the day of the procedure.

RELEASE FORMS (Required)

HIPAA Release Form
Please read and sign this form and return it to us no later than one week prior to the scheduled appointment.

Consent for Anesthesia
This form can be completed and signed the day of the procedure.

Pre-operative History and Physical Form
Please have your child's primary care physician fill out this form and
return it to us no later than one week prior to the scheduled
appointment.

INFORMATIONAL HANDOUTS

Pre-operative/Post-operative Instructions