Forms

Instructions - please review and complete steps 1-3 below. Prior to your appointment, please also review and complete the Anesthesia Deposit and Fees (Clickable Link) to sign the Financial Agreement and submit your deposit. Pre-Anesthesia and Post-Anesthesia Instructions are listed below (in the lower section of this page) for you to review.

  1. Review and submit the New Patient Registration Form

2. Review and submit the Informed Consent for Anesthesia

3. Review Pre-Anesthesia/Post-Anesthesia Instructions (notify Dr. Carillo about any questions)

 

  • For your convenience, registration packets have been created to print for those who prefer to complete the forms in writing. After printing and completing the forms, please scan and email them back to admin@evergreenda.com or fax to (833) 575-2064. After emailing or faxing your forms, please notify Dr. Carillo to verify completion. 

  • Following removal of teeth, please refer to Oral Surgery Post-Operative Instructions

  • Additional Forms and Information at the bottom of this page includes our Letter of Necessity, Statement of Anesthesia Services, HIPPA Policy and Notice of Nondiscrimination.

 

Pediatric Registration Packet (to print)

New Pediatric Patient Registration Packet

(Overview, Medical History Questionnaire, Informed Consent, Pre-Anesthesia Instructions, Post-Anesthesia Instructions)

 

Pediatric Individual Forms (submit online)

Overview

New Patient Registration Form

Anesthesia Informed Consent

Pre-Operative Questions for Parents

Pre-Anesthesia Instructions

Post-Anesthesia Instructions 


Adult Registration Packet (to print)

New Adult Patient Registration Packet

(Medical History Questionnaire, Informed Consent, Pre-Anesthesia Instructions, Post-Anesthesia Instructions)