This form explains the risks of and pre-op instructions for intravenous and oral sedation. The form also obtains the patient's consent to perform the sedation.
Informed Consent for Intravenous Sedation and Oral Sedation
You have chosen to have intravenous sedation and/or oral sedation for your dental treatment, common procedures that are considered quite safe.
WOMEN: If you are pregnant, you are NOT a candidate for Sedation.
Nevertheless, any anesthesia carries some risk and the common risks are noted below for your review before you consent to its use:
1. Allergic reactions (previously unknown) to any of the medications used.
2. The effects of the anesthetic or sedative medications may cause prolonged drowsiness, light-headedness, headache, visual disturbances, amnesia, and nausea. Nausea and vomiting, although not common, are potential side effects of anesthesia. Bed rest, and sometimes medications, may be required for relief.
3. You MUST be accompanied by a responsible adult to drive you to and from surgery, and stay with you for several hours until you have recovered sufficiently to care for yourself. During your drive home, your seat in the car should be in the reclined position. When you arrive home, lie down with your head elevated. During recovery time (normally 24 hours), you should not drive, operate complicated machinery or devices or make important decisions, including watching children and cooking.
ABSOLUTELY NO RECREATIONAL DRUGS OR ALCOHOL 24 hours before or after treatment.
4. You must have a completely empty stomach. It is vital that you have NOTHING TO EAT OR DRINK for six (6) hours prior to your anesthetic. TO DO OTHERWISE MAY BE LIFE-THREATENING! Take regular medications or prescriptions prescribed by your physician, with clear fluids (water, tea, Gatorade, and apple juice), unless told to do otherwise. You may drink clear liquids and have plain jello up to two hours prior to your appointment.
5. Nitrous Oxide (laughing gas) may be used in conjunction with the sedation.
6. You must report any and all personal illness or allergies (including diabetes) - no matter how insignificant they may seem.
7. You must also disclose any medication or drugs, prescribed or recreational, you have taken within the last three weeks, including but not limited to heroin, crack, cocaine, methadone, methamphetamine, Duragesic patch, Percocet, Vicodin, opium, and/or marijuana.
RISKS ASSOCIATED WITH INTRAVENOUS SEDATION ONLY:
1. Discomfort, swelling or bruising at the site where the drugs are placed into a vein, which may include vein irritation, called phlebitis. Sometimes this may progress to a level of discomfort where arm or hand motion may be restricted. Further medication or care may be required, which may require hospitalization.
2. IV sedation is a medical procedure that in very rare instances carries with it the risk of brain damage, stroke, heart attack or death.
Be on time for your appointment. Wear loose fitting clothing with sleeves that can be drawn up past the elbow, and wear low heeled shoes. Remove contact lenses. Remove fingernail polish and/or artificial nails on at least one finger.
WOMEN ONLY: Patients who are breastfeeding need to prepare for feedings post appointment; pump and discard for a minimum of 24 hrs after being sedated.
Sedation is intended to make your dental treatment a comfortable experience. It is suitable for most people, but if you are not in good health or if you are taking medication, you need to let us know, so the sedation can be modified to suit your needs. These instructions are so important that failure to observe them will automatically result in cancellation of your treatment that day.
IV Conscious Sedation affects everyone in a different manner. If additional medication is required to properly sedate you, a $50 charge may be added to your account. If our attempt to sedate you is deemed by your provider to be unsuccessful, you may be referred for general anesthesia.
I have read and understand the above paragraphs and realize that intravenous sedation and/or oral sedation carries with it certain serious risks. I request that intravenous and/or oral sedation anesthesia be used for my surgery. All my questions regarding this consent have been answered fully and to my satisfaction, and I fully understand the risks involved. I certify that I speak, read and write English
Please Sign Here (Patient)
[x] I attest that I have discussed the risks, benefits, consequences, and alternatives to this treatment with the patient who had the opportunity to ask questions, and I believe my patient understands what has been explained
Please Sign Here (Dentist)
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