New Patient Paperwork

New Patient Paperwork
Sweet Dreams, LLC – Patient Demographics:
Name*

First NameLast Name
Gender*
Birthday*

MonthDayYear
Age*
Parent/Guardian (If Applicable)

First NameLast Name
Relationship to patient
Phone Number*
Email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

	Please select
Asthma
Shortness of Breath
Cough
Chronic Bronchitis
Lung Disease (COPD)
Snoring
Sleep Apnea
Stomach Ulcer
Reflux (GERD)
Hiatal Hernia
Liver/ Hepatitis (Any)
Diabetes
Thyroid Problems
Arthritis/Artificial Joints
Glaucoma
Angina / Heart Attack
Heart Surgery/Stents
Heart Trouble
Heart Murmur
Rheumatic Fever
High Blood Pressure
Low Blood Pressure
Arrhythmia (Irregular heart rhythm)
Palpitations
Vascular Problems
Hay Fever
Sinus Trouble
Cancer
Cancer Treatment
History of a Stroke (CVA, TIA)
Epilepsy/Siezures
Fainting/Vertigo
Balance/Walking Issue
Migraines
Kidney Disease
Bladder Disease
Anemia
Blood Disorders
Depression/Anxiety
ADHD
Psychiatric Treatment
Ilicit Drug Use (Any)
Recreational Drug Use
Any Other Conditions

Sweet Dreams, LLC – Pre and Post Anesthesia Instructions

Fasting is essential for your safety. Failure to follow these instructions will result in cancellation of anesthesia and a broken appointment fee.
Pre Anesthesia Instructions:

Fasting Guidelines

Pediatric Patients (Ages 0–12):

• Stop solid food or a light meal 6 hours before the procedure

• Stop breast milk 4 hours before the procedure

• Clear liquids (water, Gatorade, apple juice) are allowed up to 2 hours before

Adult Patients:

• Stop solid food 8 hours before the procedure

• Clear liquids (water, Gatorade, apple juice) are allowed up to 2 hours before

Patients with reflux or delayed stomach emptying:

• No food or drink for 10–12 hours before the procedure

Day of Procedure

• Take regular medications with a small sip of water, unless instructed otherwise

• Bring inhalers, insulin, glucose monitors, and essential medical supplies

• Wear loose clothing with short sleeves for IV access

• Remove jewelry, makeup, nail polish, and contact lenses

• Call us if you’re sick: Fever (≥100°F), cough, sore throat, or recent illness

Important Reminders

• A responsible adult must drive you home and stay with you the rest of the day

• Parents: Please arrange childcare for siblings. You will need to stay available for your child and will not be allowed in the treatment room

• Payment is due at the time of service for anesthesia
Post-Anesthesia Instructions

Common temporary side effects:

• Drowsiness, confusion, or forgetfulness
• Mild nausea or low-grade fever
• Blurry vision, dizziness, or rash

These usually go away within 2–4 hours.

Call your anesthesia provider if:

• Vomiting lasts longer than 6 hours
• Fever exceeds 100°F
• Pain is not controlled with over-the-counter medication
• You notice extreme sleepiness or refusal to eat/drink after 6 hours

Call 911 or go to the ER if:

• Difficulty breathing
• Sudden changes in alertness
• The patient is unresponsive or difficult to wake

Eating & Activity Guidelines

• Start with clear liquids, then soft foods. Resume a normal diet when tolerated
• Rest for the remainder of the day
• Do not drive, operate machinery, or return to school/work until the next day or as advised
• Avoid sports, climbing, or strenuous activities

Pain Control
You may give:

• Acetaminophen (Tylenol)
• Ibuprofen (Advil or Motrin)

These can be:

• Taken together every 6–8 hours
• Or alternated every 3–4 hours
Follow the dosage instructions on the label or your provider's advice.

Sweet Dreams, LLC – Anesthesia Consent Form:

Anesthesia Consent and Acknowledgment of Risk
Pre-Anesthesia Compliance
• I have reviewed and understood the pre-anesthesia instructions provided to me.
• I understand that I must carefully follow these instructions again on the day of my procedure.
• I agree to follow all post-anesthesia care instructions as directed.
• I have had the opportunity to ask questions and discuss concerns with my doctor or anesthesia provider, and all my questions have been answered to my satisfaction.

Acknowledgment of Risks
I understand that while anesthesia is generally safe, there are potential risks and complications, which may include but are not limited to:

• Allergic reactions
• Breathing or circulatory problems
• Organ or nerve damage
• Brain injury
• Death (although rare)
I acknowledge and accept the above risks associated with anesthesia.

Financial Responsibility
I understand that if I require emergency medical transportation or treatment at another facility, I am financially responsible for any associated costs not covered by insurance.

Consent for Anesthesia
I understand that this form is being signed in advance of my scheduled procedure.
I consent to the administration of anesthesia on the date of my procedure.
I understand that I may be asked to verbally reconfirm my consent on the day of my procedure.
Patient Name

First NameLast Name
Parent/Guardian Name (if applicable):

First NameLast Name
Relationship to Minor (if applicable):

First NameLast Name
Date

MonthDayYear
Date
Signature

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Sweet Dreams, LLC – Medicaid Information:

Sweet Dreams, LLC does not process private insurance claims. Sweet Dreams does accept Medicaid coverage. If you DO NOT have Utah Medicaid please continue.
Does the patient have Medicaid coverage?

YesNo
Medicaid ID #
Medicaid ID Card Photo Upload
For MEDICAID patients: Does the patient have primary insurance in addition to Medicaid coverage?

YesNo
Medical Insurance Company
Insurance Card Photo Upload
ID Number
Group Number
Policy Holder

First NameLast Name
Date of Birth

MonthDayYear
Date
Subscriber's Relationship to Patient

Sweet Dreams, LLC – Anesthesia Payment Policy:

Sweet Dreams, LLC is committed to providing safe and professional anesthesia services. Please review the following payment policies carefully:
Insurance Policy: Sweet Dreams, LLC does not process private insurance claims. Medicaid coverage is accepted, and current Medicaid eligibility must be presented to the anesthesia provider at the time of service.

Payment Terms: Payment for anesthesia services is due on the date of service. Accepted payment methods include credit card, debit card, HSA, and cash. Personal checks and CareCredit are not accepted.

Anesthesia Fees: A minimum charge of $400 applies for the first hour of anesthesia.
After the first hour, anesthesia charges will be $100 for every additional 15 minutes of anesthesia provided.

Insurance Reimbursement: Upon request, a receipt can be provided for personal insurance claim submission. Please allow up to two weeks from the date of request for processing.

Delinquent Payments: Any unpaid balances may be referred to a collections service and may be subject to penalty fees.

By signing below, I acknowledge that I have read, understood, and agree to the above anesthesia payment policies.
Date

MonthDayYear
Date
Signature

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Sweet Dreams, LLC – Broken Appointment Policy:

At Sweet Dreams Utah, each anesthesia appointment requires significant planning, coordination, and resource allocation. To maintain availability and fairness for all patients, we have established the following policy:
What Is Considered a Broken Appointment?

No-Show
Failing to arrive for a scheduled appointment without prior notice.

Late Cancellation
Canceling or rescheduling your appointment with less than three (3) business days' notice.

Failure to Follow Pre-Procedure Instructions
Not following essential guidelines — such as fasting (NPO) — resulting in the procedure being canceled on the day of service.

Broken Appointment Fee
A $100 broken appointment fee will be charged regardless of whether or not you reschedule with us.

This fee helps cover the time and resources allocated specifically for your procedure and is necessary to avoid disruption in care for other patients.

Payment Policy
While we do not collect credit card information in advance, we reserve the right to bill or collect payment after any broken appointment, as defined above.

Thank you for your understanding and cooperation. This policy helps us deliver timely, high-quality care to all of our patients.
Acknowledgment*

I have read and understand the Broken Appointment Policy. I agree to the terms, including that the $100 fee will be charged whether or not I choose to reschedule.
Date

MonthDayYear
Date
Signature

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Should be Empty:

	No	Yes	Further Information /Explain
List any previous operations/procedures. When and Why?
Previous anesthesia problems/adverse events/reactions?

New Patient Paperwork

Sweet Dreams, LLC – Patient Demographics:

Sweet Dreams, LLC – Medical History:

Sweet Dreams, LLC – Pre and Post Anesthesia Instructions

Sweet Dreams, LLC – Anesthesia Consent Form:

Sweet Dreams, LLC – Medicaid Information:

Sweet Dreams, LLC – Anesthesia Payment Policy:

Sweet Dreams, LLC – Broken Appointment Policy: