Informed Consent For Treatment Under Oral Sedation Form printable pdf download

AV Dental Care

Informed Consent for treatment under oral sedation

Patient name_______________________________________

I hereby authorize Dr. Alvin Vasquez and any associates to perform the following procedure under Halcion.

AV Dental Care has explained to me the proposed treatment and the anticipated results of such treatment. I understand this is an elective procedure and

that there are other forms of treatment available, including the option of no treatment. I also understand that I will bring a responsible adult with me and

they have permission to make any decisions for me in the case that I am not able to make them myself.This person must be 18 years or older. You may also

want to designate in writing a person to make any needed decision regarding your treatment while you are in a sedated state. If you do not designate such a

person, you authorize the dental practice doctors to use their professional judgment in making decisions regarding your treatment as the circumstances

warrant in fulfilling the health-related, functional and aesthetic objectives set out in your treatment plan and clinical records. I understand thatunforeseen

circumstances may arise that maynecessitate a decision being made on my behalf. I have the right to designate the individual who will make such a

decision.___________________initial

Due to a possible amnesia effect, you should also arrange to have a trusted friend or loved one with you in the 24 hours after your treatment. I understand

the prescribed protocol that willbe used during my enteral conscious sedation. It isessential to have another person accompany me to myvisit to provide for

my transportation andcare. _______________initial

The combination of surgery, anesthetic, prescriptions and other factors may cause drowsiness and lack of awareness and coordination. This can be increased

by the use of alcohol or other drugs. I agree not to operate any motor vehicles or hazardous equipment if under the influence of an oral sedative for at least

24 hours. I understand that it is a requirement to have a responsible adult drive me home following any treatment under this prescription. I also understand

that if you are being orally sedated a responsible adult 18 yrs or older must stay on premises until the procedure is completed.

1. BACKGROUND INFORMATION. This form is designed toprovide information regarding the use of oral sedationagents (triazolam, diazepam, lorazepam,

midazolam,zaleplon, and or hydroxyzine). We have tried to provide thefollowing information about these agents in “plain English”and your cooperation and

understanding of this material isnecessary as we strive to achieve the best results for you.Oral sedation of the type produced by these agents hasproven to

be useful in controlling the fears of many dentalpatients. The properties of these agents have allowed manypatients to receive dental treatment in a safe,

relaxed statewith a reduction in their level of fear and anxiety. However,your awareness and ability to respond will be decreased.Like all medications, though,

there are limitations and risks(which will be discussed below), and absolute success oftreatment with oral sedatives is variable and cannot beguaranteed. I

understand that conscious sedation haslimitations and risks and absolute success cannot beguaranteed. I further understand that conscioussedation is a drug

induced state of reduced awarenessand decreased ability to respond. My ability to respondnormally returns when the effects of the sedative

wearoff._______________initial

2. CANDIDATES FOR ORAL SEDATION. We endeavor todetermine eligibility for treatment with oral sedatives throughinformation gathered during our

consultation and screening.While many individuals will qualify for treatment with oralsedatives, not all people are candidates for it. If thissituation occurs,

the doctor will discuss his/her findings withyou, perhaps along with certain other possible treatments oroptions as appropriate. Women who are pregnant,

withlikelihood to become pregnant or lactating should notuse oral sedatives (as it may cause fetal damage) norshould people with a known sensitivity to

thebenzodiazepine class of medication. Also, patients shouldnot consume alcohol while taking oral sedatives or increasethe prescribed dosage. If you have

been taking anypsychiatric mood altering drug, have a bowel obstruction, orany acute respiratory conditions such as cold, flu, or sinusinfection, you may not

be a good candidate for the use oforal sedation. Please notify the doctor if you have any ofthese conditions to discuss other options that may beavailable. I

understand that I must notify the doctor if Iam pregnant, may be pregnant, or if I am lactating. Imust notify the doctor if I have sensitivity

tobenzodiazepines, if I have recently consumed alcohol,and if I am on psychiatric mood altering drug.

ALTERNATIVE OPTIONS-Please note that there are othersedation options available for your procedure includingnitrous oxide, which is relaxation gas known

as laughinggas, topical anesthetic, which is a numbing gel that can beplaced in your mouth and give you more comfort, andintravenous sedation, which will

provide a sedative throughyour blood system to achieve sedation. These and othermethods can often be a valid alternative to enteralconscious sedation.

Other alternatives are to have notreatment performed or no pain medications or sedativeagents used. If you have any questions regarding anytreatment

alternatives, please ask your treating dentist oryour treatment consultant. I understand and have beeninformed of my possible alternative options to

enteralconscious sedation._______________initial

5. RISKS & INCONVENIENCES. Virtually all forms ofmedication, including oral sedatives, have some risks andpossible side effects. Pain medication or

sedative agentscan, among other things, alter your judgment and workperformance, and you should plan accordingly. With oralsedation, you may experience

relaxation or drowsiness, areduced sense of fear or anxiety, increased tolerance todiscomfort, an altered perception of time, tinglingsensations, giddiness or

lightheadedness, clumsiness, orunsteadiness, nausea, hallucinations or dreams. Lesscommon side effects include blurred vision, memory loss(which many

people deem desirable for dental treatment),or “rebound insomnia'” for several days. Rare side effectsinclude agitation, behavior changes,

convulsions,hypotension, skin rash or itching, sore throat, fever, chills,unusual tiredness, increased heart rate, hyperactivity orweakness may occur. If you

experience any unpleasantaffects, before or after your procedure, please inform thedoctor or assistant as soon as possible. There is also achance of an allergic

reaction to the sedation medicationwhich may include: itching, hives, redness of the skin,

I acknowledge that the AV DENTAL CARE has explained to me in general termsoral sedation, the alternatives (including non-use) and the risks

and inconveniences. I am awareof the conditions that may preclude the use of oral sedation and confirm that I do not fall into anyof these conditions or

categories. I have been given the opportunity to ask any questions andany such questions have been answered or explained to my satisfaction. I authorize AV

DENTAL CAREto use their professional judgment to manage any conditions thatmight unexpectedly arise during the course of the procedure. By signing

below, I acknowledgethat I have been given time to read and have read the preceding information in this document. Iunderstand this form and I consent to

the administration of oral sedation.

Informed Consent For Treatment Under Oral Sedation Form

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