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Oral Sedation Consent Form
CONSENT TO CONSCIOUS ORAL SEDATION FOR RESTORATIVE AND ORAL SURGERY
Consent
*
I understand that the purpose of conscious sedation is to more comfortably receive the necessary dental care. I understand that conscious sedation is not required to provide the necessary dental care. I understand that conscious sedation has limitations and risks, and absolute success of treatment cannot be guaranteed.
*
Consent
*
I understand that conscious sedation is a medically-induced state of awareness, but that conscious sedation does not produce a state of sleep. I understand that I will retain a decreased ability to respond during the procedure, and that my ability to respond normally returns when the effects of sedation wear off.
*
Consent
*
If, during the procedure, a change in treatment is required, I authorize the dentist and the operative team to make whatever change they deem in their professional judgement is necessary. I understand that I also have the right to designate an individual who will make such a decision on my behalf.
*
Consent
*
I understand that there are risks and limitations to all dental procedures. For conscious sedation, these include:
*
Consent
*
A. Inadequate sedation with initial dosage, which may require the patient to undergo the procedure without full sedation, or require delaying the procedure.
*
Consent
*
B. Atypical reaction to sedative drugs which may require emergency medical attention and/or hospitalization, including physical reaction, altered mental state, allergic reaction, illness or other condition.
*
Consent
*
C. Inability to discuss treatment options with the doctor while sedated, should circumstances require a change in treatment plan.
*
My obligations for Conscious Oral Sedation:
Obligations
*
I will need to have arrangements made for someone to drive me to and from my dental appointment. I will not be able to drive or operate machinery, or make important decisions such as signing documents, for 24 hours after my procedure.
Obligations
*
I understand that I must notify the dentist if I am pregnant, have sensitivity to any medication, have recently consumed alcohol, or if I am presently on psychiatric mood-altering drugs or other medications. I must notify the dentist of any concerns with my present mental or physical condition.
Obligations
*
I must have a completely empty stomach before undergoing the procedure.
IT IS VITAL THAT I HAVE NOTHING TO EAT OR DRINK FOR EIGHT (8) HOURS PRIOR TO ORAL SEDATION. Regularly taken medications can be taken with water only.
I have read and understood the risks and complications which may occur in connection with this procedure. I understand that the potential risks are not limited to those described above. I agree that I have been given and understood enough information to give my consent for the above procedure and to any other treatment or service deemed necessary or advisable. I have had the opportunity to ask questions and all such questions have been answered to my satisfaction. I have given a full and accurate report of my medical history, including allergies, conditions, medications and history of illness. I authorize and agree to undergo the procedure.
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Name
*
First Name
Last Name
Patient/Guardian Signature
*
Treatment Provided by:
*
Dr. Arash Boroumandi
Dr. Lorne Wasylucha
Dr. Arash Boroumandi
Dr. Ahmad Al-Ashi
Height
*
Weight
*
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Phone
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