• Do not bring personal belongings to appointment (ex: phone, purse, jewelry, watch, etc.) KASEY DAVIS DENTISTRY IS NOT RESPONSIBLE FOR BELONGINGS LOST BEFORE APPOINTMENT.
• Do not use stimulants before your appointment (caffeine/nicotine), unless otherwise directed. If you are a smoker please refer down to guidelines for smokers and follow them ACCORDINGLY  
• Do not eat or drink 6 hours prior to treatment, except sips of water to take your medications.
• Do not wear contact lenses during your appointment. 
• Do not drink grapefruit juice 12 hours before your appointment.
• Do not drink alcohol or use recreational drugs 24 hours before or after your appointment.

• Do take 5 mg of Diazepam (1 pill) right at bedtime the night before appointment, unless other dose is given.
• Do have an adult (18 years or older) bring you and escort you inside our office and not leave until you, the patient, is assisted by an assistant or doctor.
• Do wear loose, comfortable clothes to your appointment. Do take all your medications (blood pressure medicine, etc.) as you normally would the morning of your sedation appointment.
• Make sure there is NO CHANCE of pregnancy
• Bring inhaler with you if you have asthma
• Eat a VERY LIGHT breakfast 1 hour before appointment if you are diabetic or hypoglycemic (e.g. low fat yogurt, dry toast, small juice)

AFTER APPOINTMENT: 

• Make no important decisions or plan on working for 24 hours.
• NO driving for 24 hours.
• Take 2 extra strength Tylenol and 2 Advil every 4 to 6 hours after treatment for discomfort. NO sedatives should be taken for 24 hours after appointment (alcohol included).
• An adult (18 years or older) must pick you, the patient, up promptly and stay with you for the duration of the day.
• Following your appointment, keep hydrated as much as possible.
• NO stimulants after appointment (caffeine/nicotine).
• NO operating hazardous devices, heavy lifting or stair climbing until you have completely recovered.
  

• Smoke less than 1/2 pack a day: REFRAIN FROM SMOKING 12 HOURS PRIOR TO SEDATION APPOINTMENT
• Smoke between 1/2 to 1 pack a day: REFRAIN FROM SMOKING 8 HOURS PRIOR TO SEDATION APPOINTMENT
• Smoke between 1 to 1 1/2 packs a day: REFRAIN FROM SMOKING 4 HOURS PRIOR TO SEDATION APPOINTMENT
• If you smoke more that 1 1/2 packs a day: SMOKE JUST PRIOR TO SEDATION APPOINTMENT 
  

Please designate below the name and telephone numbers for your designated driver (who must be 18 years of age or older): 

Name of driver: 

Phone Number: 

Upon releasing you to your designated driver, we will need to go over after care instructions specific to the procedures that were done during the appointment.  Please initial for your consent for us to do so.

Women only: No Chance of Pregnancy (please initial)