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DENTAL ANESTHESIOLOGY AGREEMENTBETWEEN ANESTHETISTS OF WASHINGTON, LLC(Name of Dental Office)DBA AOW, LLC AND (Name of Dental Office)CONTRACT FOR ANESTHETISTS OF WASHINGTON, LLC AND 1. PURPOSE OF CONTRACTTo provide a written agreement between Anesthetists of Washington, LLC dba AOW and , herein after referred to as "Dental Office." As established by the Dental Quality Assurance Commission (DQAC), and codified under WAC 246-817-778, dentists in Washington state without a general anesthesia permit, shall establish a written contract with the anesthesia provider to ensure that when anesthesia is provided, all facility, equipment, monitoring and training requirements shall be met. 2. TERMSOn this date, AOW and Dental Office, agree to adhere to the requirements relating to administration of general anesthesia in dental offices without a general anesthesia permit in the state of Washington. AOW and Dental Office, agree to fulfill their respective responsibilities as outlined:ANESTHETISTS OF WASHINGTON, LLC RESPONSIBILITIESA.AOW is responsible for pre-, intra-, and post-operative anesthetic management of patients receiving monitored anesthesia care and general anesthesia. Anesthetists of Washington, LLC agrees to ensure that all anesthesia related requirements as listed in WAC 246-817-701 through 246-817-790 have been met.B.AOW, shall provide and maintain patient monitors, infusion pumps, and other anesthesia equipment including defibrillator and video laryngoscope.C.AOW, shall provide and maintain all required emergency medications to include: bronchodilator, sugar (glucose), aspirin, antihistaminic, coronary artery vasodilator, and anti-anaphylactic agent. D.AOW, shall keep electronic and/or paper narcotic logs available and current as per DEA regulations and as outlined in WAC 246-817-350.E.AOW, shall utilize and maintain secure electronic and/or paper patient records which document the following information during the procedure: 1) blood pressure2) heart rate3) respiration4) pulse oximetry5)end-tidal CO26) drugs administered including amount and time administered7) length of procedure and8) any complications of anesthesia F.AOW, shall provide all disposable anesthesia supplies. G.AOW, shall provide twenty-four hour, on-call availability following any anesthesia procedure we provide, excluding those procedures using only local anesthetic. H.AOW, agrees to maintain all required state and national licensure and certifications, and to stay current with mandatory continuing education and training requirements for Certified Registered Nurse Anesthetists. I.AOW has the sole responsibility to ensure that all anesthesia related requirements, as set forth under 246-817 WAC, have been met.1. If any anesthesia requirements are not met, regardless of whether the responsibility to meet such requirement lies with AOW or Dental Office, AOW shall withhold providing anesthesia services until such time that all issues impeding the anesthesia service have been corrected.DENTAL OFFICE RESPONSIBILITIESA.Dental Office agrees and will certify that all office staff and dentists maintain all certification as required by Washington state law, such as basic life saving and any and all other licensure as specified in Washington Administrative Code (WAC).B.Dental Office is responsible to maintain standard dental equipment and setup as specifically outlined in WAC 246-817-770 (5a - 5f) and listed as follows:1) An operating theater large enough to adequately accommodate the patient on a table or in an operating chair and permit an operating team consisting of at least three individuals to freely move about the patient;2) An operating table or chair which permits the patient to be positioned so the operating team can maintain the airway, quickly alter patient position in an emergency, and provide a firm platform for the administration of basic life support;3) A lighting system which is adequate to permit evaluation of the patient's skin and mucosal color and a backup lighting system of sufficient intensity to permit conclusion of any operation underway at the time of general power failure;4) Suction equipment capable of aspirating gastric contents from the mouth and pharyngeal cavities. A backup suction device must be available;5) An oxygen delivery system with adequate full face masks and appropriate connectors that is capable of delivering high flow oxygen to the patient under positive pressure, together with an adequate portable backup system;6) A recovery area that has available oxygen; adequate lighting, suction, and electrical outlets. The recovery area can be the operating theater.3. General ProvisionsA.Choice of Law. This agreement is subject to the laws and regulations of the state of Washington.B.Severability. In the event that any of the covenants herein contained shall be held unenforceable or declared invalid for any reason whatsoever, such unenforceability or invalidity shall not affect the enforceability or validity of the remaining provisions of this Agreement and such unenforceable or invalid portion shall be several from the remainder of this Agreement. C.Effective date. This Agreement shall be effective startingDateThis contract will remain in force unless either party provides the other with written notice of termination. DentalOffice SignatureName, Credentials and DateDentist or Authorized Person Kevin Gurney, CRNA, ARNPAnesthesia Provider SignatureOwner, AOW ................
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