Anesthesia Booking Sheet

Print this form and fax to schedule anesthesia services for your dental office or implant center.

Larkspur Anesthesia

Mobile Anesthesia Services

Please fax completed form to: (970) 236-2094

HIPAA Secure / Compliant

Date of Request:

Employee Name:

Pt Name:

DOB:

Phone:

Email:

Dr. Name:

Est Dr. Time:

Procedure:

Preferred Date:

Preferred Time:

BMI > 35

HTN

DM 1/2

OSA

CAD / Cardiac Stents

GLP-1

GERD

Pacemaker/AICD

Problems w/ Anesthesia

Patient Vitals:

Ht:

Wt:

BP:

HR:

SpO2:

Temp:

Allergies:

Patient Medications:

Notes / Additional Medications:

Confirmed:

Pre-Op Call:

www.LarkspurAnesthesia.com | (970) 964-9379 | LarkspurAnesthesia@gmail.com

Fax completed form to: (970) 236-2094

For urgent requests, please call or text us at 970-964-9379