Pleasant Dreams Dental Anesthesia - Anesthesia Agreement and Confirmation

Anesthesia Agreement and Confirmation

I have been informed and understand the terms and conditions for Dr. Donald Lee/Dr. Paek
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will not have anything by mouth after 10:00pm the night before the appointment, including water or brushing teeth the morning of.
Please verify that you are authorized to complete this information and it is true to the best of your knowledge.
Parent/Guardian

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Date

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Date
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