Pre-Appointment Checklists

CONSULTATION AREA SUPPLIES

Checklist #1

Please have the receptionist prepare the consultation area prior to my arrival to include the following items:

• Patient should have already received the Pre-Operative Instructions for Dental Surgery (1 of 9)
• Surgical treatment plan and associated fees (attached to outside of patient's chart)
• Have patient complete an updated Medical History Update Form (2 of 9)
• X-ray attached to outside of chart:
  • Panoramic is mandatory for all 3rd molar extractions.
  • Periapicals are acceptable for all other extractions.
  • All X-rays must be less than one (1) year old.
• Oral surgery forms--inside or attached to the chart:
  • Medical Consultation Form (3 of 9)
  • Patient Treatment Record (4 of 9)
  • Moderate Sedation Record (5 of 9)
  • Disclosure & Consent--Dental & Oral Surgery (6 of 9)
  • Nerve Injury Disclosure & Consent (7 of 9)
  • Post-Operative Instructions Following Dental Surgery (8 of 9)
  • Acknowledgment:  Notice of Privacy Practices (9 of 9)
• Post-operative gauze package (preferably in an autoclave bag)

If patient is having IV sedation:

• Ask patient to use restroom, if necessary, prior to my arrival.
• Remind patient not to eat or drink at least six (6) hours prior to appointment.
• Remind patient that they must have an escort to accompany them to the office, to remain with them throughout the procedure, and to take them home following the procedure.

OPERATORY (SURGICAL) SUPPLIES

Checklist #2

Please have your assistant prepare the surgical operatory prior to my arrival, to include the following items:

• Local anesthetic:
  • 2% Lidocaine w/ 1:100000 epi--2 carp
  • 0.5% Marcaine or Vivicaine w/ 1:200000 epi--4 carp
• Patient bib x 6 (per patient)
• Four (4) monoject #412 syringes (per patient)
• Dry gauze 4 x 4
• Dental floss
• Alcohol gauze
• #15 scalpel blade x 2 (per patient)
• 3° or 4° gut sutures (3° chromic gut preferred)
• Two (2) 25 gauge long, yellow local anesthesia needles (per patient)
• Medium & small gloves
• Large sterilization bags (9" x 15")--three (3) per patient
• Nitrous unit (w/ tanks turned on and mask in place)
• Three (3) Dixie (or plastic) cups