Patient Intake

Please complete this form for each patient you've booked Dr. Arce to provide sedation services for. You only need to submit this once per patient.

Sedation fees — paid in full directly to In-Office Specialist LLC. No insurance billing, no percentage deductions: the fee listed is what Dr. Arce receives.

Oral sedation — $500
Moderate IV sedation — $2,000 (up to 4 hours)

Payment via Zelle: 281-760-9270

OfficeOffice name *Your email (office contact) *We'll use this for any follow-ups about this patient.

PatientPatient's full name *Patient's date of birth *Patient's phone number *Patient's email *

ProcedureSedation type *Who is responsible for the bill? *

Visit duration

Half day (4 hours — one AM or PM slot)Full day (8 hours — book both AM and PM)

Picking Full day changes the confirmation email so you're reminded to book both slots on the calendar.

You'll pick the appointment date/time on Dr. Arce's calendar after submitting this form.

ClinicalPatient allergies *Preferred pharmacy *Medical history (PDF, up to 5 files, 50 MB each) *Files upload directly to Dr. Arce's secure Drive folder; no patient data passes through this site's server.