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Patient Forms

Patient Forms for Children Under 12 Years of Age

Anesthesia Cover Letter—Child
Medical History Form—Child
Pre- and Post-Anesthesia Instructions—Child
Informed Consent for Anesthesia—Child
Financial Agreement-Child


Formularios en Español

Consulta Dental Bajo Anestesia General
Historia Médica Pediátrica
Instrucciones Pre-Anestesia y Post-Anestesia
Autorización Para el Uso de Anestesia en Menores
Acuerdo de Pago Para La Anestesia Dental Pediátrica


Patient Forms for Adults and Children 12 Years and Older

Anesthesia Cover Letter—Adult
Medical History Form—Adult
Pre- and Post-Anesthesia Instructions—Adult
Informed Consent for Anesthesia—Adult
Financial Agreement Form—Adult


Forms for Dental Office Usage

Patient Scheduling Forms
Patient Scheduling Form in MSWord Format to be Filled Out Electronically
Directions for Using the MSWord Electronic Patient Scheduling Form
Patient Scheduling Form in PDF format

        Patient Fee Schedules
Fee Schedule for Children Under 12 Years of Age
Fee Schedule for Adults and Children 12 Years of Age and Older

The Humanitarian Foundation Grottoes of North America (financial help for special-needs children)
Information to Obtain Financial Help for Your Special-Needs Patients

Dr. Fisher does not bill insurance. The following form letters may be helpful to you in obtaining anesthesia pre-authorization for your patients.
Insurance Pre-Authorization Form Letter—form to be filled out on the computer
Insurance Pre-Authorization Form Letter—print and fill out by hand 
(Save these form letters to your own computer for convenient usage. To fill in the form on the computer, place your curser after the Date: field and click. When the curser begins to blink, you can start typing. Use the TAB key to move to the next and following fields.)

Physician's Pre-anesthesia Medical Evaluation Form
Pre-anesthesia Medical Evaluation Form