Referral Form
Patient Information
Radiographs
Teeth to be Removed
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
|||||||
Appointment Information
Provider
11551 Granada Lane, Ste 100 Leawood, KS 66211 Phone: (913) 491-4488 Fax: (913) 491-5073
8919 Parallel Pkwy, Ste 480 Kansas City, KS 66112 Phone: (913) 334-6000 Fax: (913) 334-7990
SLEEP PATIENTS ONLY
1. If your appointment is in the morning do not have anything to EAT or DRINK after midnight the night before surgery. Or if your surgery is in the afternoon nothing to EAT or DRINK for at least 6 hours before surgery.
2. If you are taking any medications for blood pressure or other conditions, or you need to take an antibiotic to pre-medicate for artificial joints or heart murmur you may take this medication with the smallest amount of water possible.
3. If you have asthma please bring your inhaler with you for surgery.
4. An adult must be with you who will stay in the waiting room the entire time you are here. You cannot drive yourself home if you have been sedated. A parent or legal guardian must accompany any minor.
5. Wear tie-shoes and loose-fitting clothes with short sleeves the day of surgery (no ties or tight sleeves). No slip-on sandals which would cause you to trip while walking after being sedated.