Step 1 of 8 - Personal data child

Child's name*

Child's first name * Child's name *

Date of birth*

Age

National registry number*

Weight

Length

Date of operation (if already known)

Referring dentist

GP name

GP phone number

Naam verijzende tandarts/praktijk

Adres verwijzende praktijk

Name mother / father / guardian*

Phone number parent(s)/guardian(s)*

E-mail address parent(s)/guardian(s)*

Address*

I follow the conventions of being sober. I do not give my child solid food, milk products or fruit juices in the 6 hours before arriving at the practice. I allow my child to drink some sugared water up to 1 hour before arriving at the practice.
If these rules are not followed, the anesthesiologist may postpone the procedure to a later time.
I give my child the day of surgery only medication indicated by the anesthesiologist.
Jewelry and piercings I removed from my child.
If the dentist or anesthesiologist deems it necessary during the procedure, my child will be referred to the hospital.
As part of internal quality control, I agree to my and/or my child's data being processed anonymously.
I read and understood the information brochure anesthesia in children for dentistry.
- I understand that the listed list of side effects and complications can never be exhaustive.
- I give the anesthesiologist my permission to perform all actions medically necessary to maintain my son/daughter's health status during the performance of the planned procedure.
- I commit myself to follow closely all recommendations.
I agree to allow my child to undergo a dental procedure or examination under general anesthesia.
By signing this document, I agree that my contact information will be passed on to the Athoma Secretariat in connection with the procedure.

To be completed by parent or legal representative

Patient's name*

Name of parent or legal representative and kinship*

Date (today)*

Signature*

Pre-operative questionnaire children