Book an Appointment

One flow: pick a time, tell us about the patient and procedure, complete the health history, and hold the appointment with a $150 deposit. The appointment is only confirmed once payment succeeds.

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Date

Patient

Care Team

Profile

History

Habits

Ability

Heart/Lungs

Neuro/Gen.

Consent

Pay

Choose a Date & Time

Patient & Contact

Asked once — used for the appointment, the health history, and the payment agreement.

Patient Full Name *

Patient Date of Birth *

Email *

Cell Phone *

Address: Street, City, State, Zip *

Emergency Contact (name & relationship) *

Emergency Contact Phone *

Procedure & Care Team

Dental Office *

Procedure *

Notes for the office (optional)

Primary Care Physician (PCP) Name *

PCP Phone Number

Medical Specialists *

None Cardiologist Pulmonologist Neurologist Endocrinologist Other

Select all that apply, or "None". Selecting a specialist opens a spot to add their contact info.

Health Profile

Age *

Gender *

Height *

Weight *

Allergies to medications *

Current medications and supplements *

Do you take any GLP-1 receptor agonist or SGLT-2 inhibitor for weight loss or diabetes? *

Semaglutide (Ozempic, Wegovy), Dulaglutide (Trulicity), Liraglutide (Victoza), Empagliflozin (Jardiance), Dapagliflozin (Farxiga), and similar medications.

Yes No

Anesthesia & Surgical History

Any problems with anesthesia before? * Yes No

Any family history of problems with anesthesia? * Yes No

List all prior surgeries and the approximate year or your age at the time *

Current & Prior Daily Habits

In the past 12 months, have you used any of the following on a daily basis?

Before the last 12 months, did you ever have a history of heavy use or addiction to:

Physical Ability

Can you do the following?

Condition	Yes	No
Lay flat on your back
Tilt your head back
Get dressed on your own
Walk briskly on flat ground for 5 minutes without stopping
Walk up a flight of stairs without stopping
Carry a bag of groceries up a flight of stairs without stopping
Walk uphill for 5 minutes without stopping
Exercise regularly

Heart

Do you have a history of or currently have:

Condition	Yes	No
Heart attack or myocardial infarction
Coronary artery disease
Heart failure
Heart valve disease
Congenital heart disease at birth
Chest pain or angina
Abnormal heart rhythm or arrhythmia
High blood pressure
Heart murmur
Pacemaker or defibrillator
Any prior heart studies (stress test, echocardiogram, etc.)
Other heart disease (explain below)

Lungs

Do you have a history of or currently have:

Condition	Yes	No
Cold, cough, or respiratory illness in the last month
Asthma
COPD or emphysema
Bronchitis
Pulmonary hypertension
Sleep apnea
Severe snoring
Restrictive lung disease
Other lung disease (explain below)

Nervous System

Do you have a history of or currently have:

Condition	Yes	No
Stroke
Epilepsy or history of seizures
Down syndrome
Developmental delay or intellectual disability
Autism
Congenital or genetic syndrome (explain below)
Cerebral palsy
Dementia or cognitive decline
Multiple sclerosis
Other nervous system disease (explain below)

General Medical Conditions

Do you have a history of or currently have:

Condition	Yes	No
Bleeding or clotting disorder
History of nose bleeds
Diabetes
Reflux or GERD
Kidney disease or kidney failure
History of urinary retention
Enlarged prostate
Incontinence
Liver disease or hepatitis
Thyroid disease
Psychiatric illness
Neck pain
Back pain
Unexpectedly hospitalized in the last 6 months

Other health conditions not listed above *

Any questions or concerns regarding anesthesia? *

Required Disclosures & Consent

Required Disclosures

Medical doctors are licensed and regulated by the state medical board. To verify a license or file a complaint, contact your state medical board directly.

The federal Physician Payments Sunshine Act requires that payments and transfers of value over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians be made available to the public through the CMS Open Payments database.

I have read the Required Disclosures.

Pregnancy Statement

Anesthesia may be harmful to an unborn child. You are responsible for informing the anesthesiologist of a confirmed pregnancy or the possibility of pregnancy.

I have read and understand the Pregnancy Statement.

Pre & Post-Anesthesia Instructions

Eating and drinking: Do not eat or drink anything for 8 hours prior to the procedure. Water only up until 2 hours prior. Failure to follow this may result in severe harm, including aspiration and possibly death.

After: Limit intake to liquids for the first hour, avoid driving or operating machinery for 24 hours, and arrange a responsible adult to escort the patient home. Full instructions are on the Pre & Post-Operative Instructions page.

I have read the Pre-Anesthesia Instructions and understand the procedure may be cancelled if they are not followed.

I have read the Post-Anesthesia Instructions.

Anesthesia Consent

Types of anesthesia range from monitored sedation to general anesthesia, chosen based on the procedure and the patient's health. Risks include, but are not limited to, allergic reaction, infection, bleeding, nerve injury, aspiration, and in extremely rare cases major organ damage, coma, or death. Alternatives include proceeding without anesthesia or postponing the procedure.

I have read the Anesthesia Consent, understand the risks, and I agree to proceed with anesthesia.

Payment Agreement

Deposit: The $150 deposit paid on the next step holds this time and is applied to the total anesthesia fee.

Balance: Any remaining balance is due the day of the procedure, before anesthesia is administered.

Insurance: Dharini Patel MD INC. does not bill insurance directly; an itemized receipt is available on request for reimbursement.

Cancellation: Less than 48 hours' notice, or a procedure that cannot proceed because pre-anesthesia instructions weren't followed, may forfeit the deposit.

I agree to the fee, deposit, balance, and cancellation terms above, and I am financially responsible for the anesthesia services provided.

Responsible Party (only if different from the patient)

Signature (type your full name) *

Today's Date *

If the patient cannot consent, this signature should be the person responsible for making medical decisions for the patient.

Review & Pay Deposit

Date & Time: —
Patient: —
Dental Office: —
Procedure: —

Deposit due now $150

Condition	Yes	No
Alcohol (more than 2 drinks per day)
Tobacco or nicotine
Marijuana
Other illicit drugs (including prescription drugs used recreationally)

Condition	Yes	No
Alcohol
Tobacco or nicotine
Marijuana
Other illicit drugs (including prescription drugs used recreationally)

Book an Appointment

Appointment confirmed

Choose a Date & Time

Available Times —

Patient & Contact

Procedure & Care Team

Health Profile

Anesthesia & Surgical History

Current & Prior Daily Habits

Physical Ability

Heart

Lungs

Nervous System

General Medical Conditions

Required Disclosures & Consent

Required Disclosures

Pregnancy Statement

Pre & Post-Anesthesia Instructions

Anesthesia Consent

Payment Agreement

Review & Pay Deposit