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For patients

Ask for anesthesia for your dental treatment

Fill in this form, print it and bring it to your dental office. Your dentist and Aspire Anesthesia will then plan your care together.

  1. Fill it inTakes about five minutes.
  2. Print or save itAs paper or a PDF.
  3. Bring it to your dentistYour office calls us, or we call them.
Private by design. Nothing you type here is sent to Aspire or saved by this website. It stays on your screen until you print it or close the page. In an emergency, call 911.
1. About the patient
The patient is
2. Your dental office
3. Dental treatment needed

Check all that apply. It’s fine to be unsure.

4. Why you are asking for anesthesia
5. Health basics (optional)

This helps the anesthesia review. We will go over your full health history with you before any treatment.

6. Timing and preferences
When would you like treatment?
Type of anesthesia