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nitrous oxide oxygen conscious sedation
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Informed Consent for Nitrous Oxide/Oxygen Conscious Sedation
Recommended Treatment
I hereby give consent to Dr.
to perform Nitrous Oxide/Oxygen Conscious Sedation procedure(s) on me or my dependent as follows:
Nitrous Oxide Sedation is commonly called laughing gas and provides relaxation. I understand that I (or my dependent) will be awake, fully conscious, aware of my surroundings, and able to respond rationally to questions and directions during the Recommended Treatment. The Recommended Treatment is used for anxiety and pain control, as well as control of gagging. Local anesthesia will also be required for most procedures. The nature and purpose of the Recommended Treatment have been explained to me and no guarantee has been made or implied as to result or efficacy. I have been given satisfactory answers to all of my questions, and I wish to proceed with the Recommended Treatment.
Treatment Alternatives
Alternative methods of treatment have been explained to me, such as extraction of the involved teeth, or postponement of root canal therapy, but I wish to proceed with the Recommended Treatment described above.
Risks and Complications
I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:
1. Nausea and vomiting.
2. Temporary tingling in the fingers, toes, cheeks, lips, tongue and head or neck area.
3. Temporary warm feeling throughout the body with accompanying flushing/blushing.
4. Temporary detachment or “out of body” sensation.
5. Temporary sluggishness in motion and/or speech.
6. Shivering (usually at the end of the procedure).
7. As a result of the injection or use of anesthesia, there may be swelling, jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.
Patient Name
Patient Signature
Date/Time
Parent or Guardian (if patient is minor)/
Witness
Patient Signature
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