Oral Sedation Consent
I authorize oral sedation, and:
I understand, through discussions with my doctor the nature and purpose of this procedure. I also understand what alternative treatments are available and the advantages and disadvantages of each, including no treatment. The alternative treatments that have been discussed are: no sedation, fear counseling, sedation with nitrous oxide, sedation with other oral sedatives, referral to a dentist who will use IV sedation or general anesthesia including going to a hospital for a general anesthetic.
I understand that there are various risks, consequences, or complications that may result from performing this procedure. I acknowledge that some of the risks, consequences, or complications include, but are not limited to: amnesia of the procedure and for some time before and after the procedure, hyperactivity (being more active than normal), dizziness, loss of coordination, sleepiness.
I understand that I need to have a responsible adult take me home after my appointment and stay with me the rest of the day. I agree that I will not drive a motor vehicle, or do anything that requires coordination or judgment including looking after children, cooking, making financial decisions, working power tools or other sharp tools for 24 hours after sedation. I can have no alcohol, tranquilizers, or other sedatives or the day of the treatment either before or after the treatment. I also grant permission to discuss my dental and sedation treatment with my accompanying adult.
I understand that there is no guarantee that the dental procedure will be successful; however, the procedure is desired and intended to result in improved oral conditions.
I agree that a verbal discussion with my doctor has outlined why the procedure is recommended, what alternative treatments are available, what risks, consequences and complications may result from the procedure, and that all my questions have been answered satisfactorily. I also agree that all blanks above on this consent form were filled in before I was asked to sign it.
Name of Driver:
Your First Name
Your Date Of Birth
Patient/Legal Guardian Signature
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