Sedation & imaging · CID-SED-04 · v1.0

Sedation Escort and Discharge Acknowledgment

Confirms who is taking you home after sedation and what you must not do afterward.

About 5 minutesRead, sign and download from your own device

Completion

0 of 18 required items

Patient details
Patient-specific fields
Acknowledgments
Electronic signature

Before you sign

Review this document before your appointment when possible. Your treating dentist must still explain the patient-specific treatment, benefits, material risks, alternatives—including no treatment—and answer your questions. Do not sign after receiving sedating medication.

1. Who this form is for

Fields marked * are required for a signed PDF.

Patient full legal name *Date of birth *Email *Phone *

Treating dentist

Dr. Jain & Dr. Gupta

Treating office *Signer full legal name *Enter the patient’s name when the patient is signing. An authorized representative must enter their own name.Relationship or authorityRequired when someone other than the patient signs.

2. What you are agreeing to

Why this is required

Sedative drugs affect judgment, reaction time, balance, and memory for far longer than they appear to. You may feel alert and still be impaired, and you may not remember conversations from the rest of the day — including instructions given to you after treatment. This is why an escort is a condition of being sedated here, not a suggestion.

Your escort must

If you arrive without an escort, your sedation appointment will be rescheduled. This is for your safety and is not negotiable.

Be a responsible adult you know.
Bring you, wait, and take you home — by car, taxi, or rideshare. You may not drive yourself, and you may not travel home alone on public transport.
Be given your post-operative instructions with you, and be reachable afterward.
Stay with you, or arrange for another responsible adult to stay with you, for the rest of the day and overnight where you have been told that is necessary.

For the rest of the day, do not

Drive, ride a bicycle or motorcycle, or operate any machinery or power tool.
Drink alcohol or take any recreational drug.
Take any medicine not approved by your dentist, including sleeping tablets and anything sedating.
Sign legal or financial documents, or make important decisions.
Care for a child or a dependent adult on your own.
Cook, or do anything else where a lapse in attention could injure you.

Call us — or call 911

Call the office for bleeding that does not settle with pressure, pain not controlled by your medication, a reaction to a medicine, or a fever.
Call 911 for difficulty breathing, chest pain, a swelling that is spreading toward the eye or down the neck, or if the patient cannot be roused.

3. Your case, in your words

Escort's full nameRelationship to youEscort's mobile numberWho will be with you for the rest of the day and overnightName and relationship, if different from your escort.

4. Confirm, then sign

I understand that I must be collected by a responsible adult, that I may not drive or travel home alone, and that my appointment will be rescheduled if I arrive without an escort.I understand that I may feel more alert than I actually am, and that I may not remember instructions given to me after treatment.I have read the list of things I must not do for the rest of the day, and I agree to follow it.I have had an opportunity to ask my treating dentist questions, and my questions have been answered in language I understand.I agree to sign this form and receive it electronically. I understand this agreement applies only to this form, and that I can complete this and any other form on paper instead — completing forms on paper does not affect my treatment, my fees, or my care in any way.I understand that I may withdraw my agreement to sign electronically at any time before I sign by simply not signing and asking the office for a paper copy, and that after signing I may ask the office for a paper copy at no charge.I understand that I need a current web browser and a device able to open and save a PDF file, that I should download and keep the PDF this form produces, and that I can ask the office to print or re-send my signed form at any time.I intend my drawn or typed signature to be my electronic signature on this form, and I am signing it myself.

Patient or authorized representative signature *

Sign inside the box using a mouse, stylus, or finger.

Where this form goes

Nothing you type here is uploaded — the signed PDF is built in your browser. Download the signed PDF saves it to your device and sends nothing. Bring it to your appointment or hand it to the front desk, and staff will place it in your dental record.

Completion

0 of 18 required items

Patient details
Patient-specific fields
Acknowledgments
Electronic signature

Need help? Call the office before signing. A patient form should document a conversation, not replace one.

Who is responsible for this document

Responsible clinicians

Dr. Sambhav (Sam) Jain, DMD, MS
Lead Implant Dentist & Founder · CA Dental License #50472
Dr. Arpana Gupta, DDS, MDS
Implant Dentist · CA Dental License #50467

Arpana Gupta, DDS and Sambhav Jain, DDS, Inc., practicing as Center for Implant Dentistry.

Where to reach us

Fremont
3381 Walnut Ave, Fremont, CA 94538
Phone (510) 574-0496 · Fax (510) 574-0499
San Francisco
4318 Geary Blvd, Suite 201, San Francisco, CA 94118
Phone (415) 696-2922 · Fax (510) 574-0499

Questions about a form? info@bayareaimplantdentistry.com — that address is for questions about a form, not for sending one. A completed form holds health details that should never travel through ordinary email: download the signed PDF and bring it to your appointment, or hand it to the front desk.

What happens to what you type

While you type, nothing is sent and no draft, analytics, or advertising script records your answers. Download builds the PDF in your browser, saves it to your device, and sends nothing — this website never transmits your completed form. Hand it to our staff at your visit so they can place it in your record. Once accepted there, it becomes part of your dental record and is protected under California’s Confidentiality of Medical Information Act (Civil Code § 56) and, where it applies, HIPAA. You can read how we handle records in our health information privacy notice.

Controlled document CID-SED-04 · v1.0 · Effective 06 Sep 2026 · Next clinical review 06 Sep 2028 · Owner Sambhav (Sam) Jain, DMD, MS & Arpana Gupta, DDS, MDS