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:
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.