Skip to content
4300 S Park Dr #270, Stony Plain, AB T7Z 2W7
About Us
Expand
Contact Us
Our Office
Expand
Dr. Dorota Szula
Blog
Services
Expand
Orthodontics
Expand
Invisalign
Myobrace
Braces
Children’s Dentistry
Dental Hygiene
Forms
Expand
Forms
X-Ray Release Form
New Patient Forms
Phone
Book Your Appointment
Toggle Menu
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.
Today's Date
*
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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
*
About Us
Expand child menu
Expand
Contact Us
Our Office
Expand child menu
Expand
Dr. Dorota Szula
Blog
Services
Expand child menu
Expand
Orthodontics
Expand child menu
Expand
Invisalign
Myobrace
Braces
Children’s Dentistry
Dental Hygiene
Forms
Expand child menu
Expand
Forms
X-Ray Release Form
New Patient Forms
Schedule Your Appointment
Phone
