Nitrous oxide informed consent

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Patient name:(Required)

I hereby give permission for Dr. _________(Please write the name of the doctor below) to perform nitrous oxide sedation. I understand that the administration of medication and the performance of conscious sedation with nitrous oxide carries certain common hazards, risks, and potential unpleasant side effects which are infrequent, but nonetheless, may occur. They include but are not limited to the following:

Name of the doctor:

1. Excessive Perspiration: Sweating may occur during the procedure and you may become somewhat flushed during the administration of nitrous oxide.

2. Expectoration: Removal of secretions may be difficult but can be controlled by the use of a suction tip.

3. Behavioral Problems: Some patients will talk excessively. You may become difficult to treat because you are so talkative, or experience vivid dreams associated with the physical movement of the body.

4. Shivering: Although not common, shivering can be quite uncomfortable. Shivering usually develops at the end of the sedative procedure when the nitrous oxide has been terminated.

5. Nausea and Vomiting: This is the most frequent of the side effects of nitrous oxide sedation but its frequency is still quite low. It is important to tell the doctor, hygienist, or assistant that you are experiencing some discomfort. The level of nitrous oxide can be adjusted to eliminate this side effect.

6. Driving a Motor Vehicle: You may not feel capable of driving after nitrous oxide. If this occurs, we will keep you until you feel better or have you call a friend or cab to ensure your safety.

I have been advised of alternative treatment, the benefits, and risks which include but are not limited to: Fear and anxiety of the dental experience and/or avoidance of future dental appointments. These fears and anxiety, if not diminished by the use of nitrous oxide sedation, may precipitate other medical problems including fainting, palpitation, and other heart-related disorders.

Some of the benefits one can expect from nitrous oxide sedation are assistance for those patients who may have anxiety or dental phobias. Nitrous Oxide can make dental procedures significantly more tolerable, minimizing pain. It can also help assist patients who have a strong gag reflex and medically compromised individuals to feel more at ease and relaxed.

I hereby certify that I understand this authorization and the reasons for the abovenamed sedative procedure and associated risks. I am aware that the practice of dentistry is not an exact science. I acknowledge that every effort will be made on my behalf for a positive outcome from sedation, but no guarantees have been made to the result of the procedure authorized above.

Once fully read and reviewed, please make sure that the above document is filled out appropriately. By signing below and submitting this document, we are assuming that it has been read in its entirety. All patient signatures will be verified for authenticity in the office.

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