1. Do You Have An Appointment?

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  2. Password
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  3. You need to make an appointment to continue. Please click here to request an appointment
  1. Your First Name
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  2. Last Name
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  3. E-mail
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  4. Preferred Contact Number
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  5. Child's Full Name
    Please type your full name.
  6. Child's Date of Birth
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  7. I understand that Nitrous Oxide will only provide relaxation and that local anesthesia may still be necessary.
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  8. I understand that Nitrous Oxide is not a ‘cure-all’ and may not be compatible with my child’s needs and that absolute success can not be guaranteed.
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  9. I understand that the administration of nitrous oxide carries with it certain risks and potential unpleasant side effects.
    These include, but are not limited to shivering, nausea and vomiting, or a 'light headed' feeling.
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  10. I accept and understand that the alternatives to Nitrous Oxide administration are:

  11. No Nitrous Oxide. The necessary procedure is performed and local anesthetic ("novocaine") is used as needed.
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  12. General Anesthesia which requires that the patient to be treated at a hospital.
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  13. I have been informed of the benefits, risks and alternatives regarding the administration of Nitrous Oxide to my child.
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  14. I am aware that the per-visit fee of $60 for Nitrous Oxide is non-refundable regardless of the visit outcome.
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  15. I am aware that I may NOT take videos or photographs of my child during treatment.
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  16. I am aware that the failed appointment fee for a Nitrous Oxide appointment is $80.
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  17. I am aware of the 48-hour cancellation policy for Nitrous Oxide appointments.
    Cancellation must be made 2 business days prior to appointment to avoid $80 fee.
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  18. I consent and authorize Dr. Capalbo to use Nitrous Oxide (laughing gas) during the treatment of my child.

  19. I certify that the information provided in this form is correct to the best of my knowledge.
    I also certify that I am the person who I claim to be and I am not falsely representing another individual.

    Use your mouse or trackpad to sign on a computer. Use your finger or stylus pen to sign on a touchscreen device.

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