Oral Sedation Information And Consent Form

This form is intended to document the discussion we have had regarding your planned conscious sedation procedure.

The medications we use are typically either Triazolam (Halcion), Lorazepam (Ativan). These medications can greatly minimize anxiety that may be associated with going to the dentist. In a relaxed state, you will still be able to communicate with the dentist while treatment is being performed. Even though it is safe, effective and wears off rapidly after the dental visit, you should be aware of some important precautions and considerations.

Benefits of conscious sedation include reduced awareness of unpleasant sights, sounds and sensations associated with the procedure along with reduced anxiety. Most patients fall asleep, but not always.

Risk of conscious sedations include nausea/vomiting, allergy to medication, irritation and/or pain/swelling to skin and veins (IV only), breathing problems, brain damage, cardiac arrest and death.

I understand that it is critically important that I fully discuss my complete medical history with the dentist before sedative medications are administered especially any medication I am taking.

**You should not use these medications if you are PREGNANT, breast feeding, or have significant liver or kidney disease.

Tell the doctor if you are taking the following medications as they can adversely interact with the sedation medications: nefazodone (Serzone); cimetidine (Tagament, Tagament HB, Novocimetine or Peptal); levodopa (Dopar or Larodopa) for Parkinsons’s disease’; antihistamines (such as Benadryl and travist); verapamil (Calan); diltiazem (Cardizem); erythromycin and the azola antimycotics (nizoral, Biaxin, ororanox); HIV drugs indinavir and nelfinavir; and alcohol. GRAPEFRUIT JUICE should also be avoided. Taking recreational/illicit drugs can also cause untold reactions.

Sedation can be administered by multiple routes. My dentist has discussed these options with me. I also understand that the sedation plan may need to be changed on the day of the procedure. I also acknowledge that no guarantee has been made as to the results that may be obtained.

During the discussion, I have had my questions answered to my satisfaction.

I, , request and authorize Aylmer Family Dental to administer oral conscious sedation medications and/or nitrous oxide/oxygen conscious sedation to me in conjunction with the planned dental treatment procedures.

Vitals