Office Anesthesia Evaluations

Attestation Form – Required Signatures

VSOMS Office Anesthesia Evaluation Policies

Criteria for Evaluation of Simulated Emergencies

New Members:

According to our Constitution and Bylaws, applicants must complete a VSOMS sponsored on-site office anesthesia evaluation in order to be considered for full membership into the Society. The evaluation, which will be conducted by VSOMS members, is based on the AAOMS Office Anesthesia Evaluation Program and is designed to ensure that you and your patients are protected when anesthesia is being used.

Once you have submitted your anesthesia evaluation application and payment, as well as the signed attestation form, you will be granted provisional membership into the VSOMS. We recommend that you apply for and complete the evaluation as soon as possible because the Virginia Board of Dentistry exempts AAOMS/VSOMS members from their sedation permit requirements only if they have completed the AAOMS anesthesia evaluation. We recommend that current members apply for their evaluations at least 90 days prior to their expiration date. Please complete the application and submit with payment. A member of the Anesthesia Committee will contact you to arrange a convenient time for your onsite evaluation as soon as possible once we have your application and payment.

Practice Information
Name of Practice*
List OMSs at Practice*
Doctor to be evaluated:*
First Last Suffix
Location Information
Primary Office Evaluation*
Primary Office Address*
Street Address Address Line 2 City State ZIP Code
Primary Office Phone
For multi-practitioner practices, each practice is only due an administrative fee and an affidavit must be submitted for each doctor practicing at office where he/she is not physically evaluated.
Satellite Offices Receiving Evaluation*
Evaluation Satellite Office 1*
Street Address Address Line 2 City State ZIP Code
Satellite Office Phone 1
Evaluation Satellite Office 2*
Street Address Address Line 2 City State ZIP Code
Satellite Office Phone 2
Evaluation Satellite Office 3*
Street Address Address Line 2 City State ZIP Code
Satellite Office Phone 3
Scheduling Information
Contact Individual*
First Last
Primary Contact for Scheduling Evaluations
Contact Telephone*
Email
Fee Information
Coupon
Primary Office Evaluation
Price:
Membership Status
- VSOMS Member
- Non Member
Satellite Office Evaluation
Price:
Price per satellite office.
Membership Status
- VSOMS Member
- Non Member
RELEASE FROM LIABILITY*
- I have read, understand, and agree with the Release of Liability.
RELEASE FROM LIABILITY: This statement certifies that I am voluntarily requesting a site visit by a member of the VSOMS Office Anesthesia Evaluation team as a part of the VSOMS Office Anesthesia Evaluation Program and that I release the VSOMS, the site examiner, and members of the Committee on Anesthesia from any liability which may occur as a result of participating in the program.
Total
$0.00
Preference
This field is for validation purposes and should be left unchanged.

Office Anesthesia Evaluations

Practice Information

Location Information

Scheduling Information

Fee Information