One copy given to the patient, another kept in the patient’s chart

One copy given to the patient, another kept in the patient’s chart. Date ____________________ Name_____________________________________ Oral Sedation Information and Consent Form Taking a sedative one hour prior to your dental appointment is an excellent way to minimize or eliminate anxiety that may be associated with going to the dentist. Even though it is safe, effective, and wears off rapidly after the dental visit, you should be aware of some important precautions and considerations. Please be here in the office one hour prior to your treatment appointment. 1. This consent form and the dental treatment consent form should be signed before you take the They are invalid if signed after you take the pills. You must have a responsible adult escort to monitor your recovery for the period the sedative lasts. 2. The onset of this family of sedative is 15-30 minutes. Do not drive after you have taken the medication. The peak effect occurs between 1-2 hours. After that, it starts wearing off and most people feel back to normal after 6-8 hours. For safety reasons and because people react differently to medications, you should not drive or operate machinery the remainder of the day. Wait until tomorrow. 3. This medication should not be used if a. Hypersensitive to benzodiazepines (Valium, Ativan, Versed, etc.) b. you are pregnant or breast feeding c. you have liver or kidney disease d. You are taking the medicines nefazodone antidepressant (Serzone); cimetidine (Tagament, Tagament HB, Novocimentine, or Peptol); or levadopa (Dopar or Laradopa) for Parkinson’s disease. The following substances may prolong the effects of the sedative: Benedryl; Phenergan; Calan (verapamil); Cardizem (diltiazem); erythromycin; HIV drug indinavir and nelfinovir; and alcohol. There may be unusual and dangerous reactions if you are currently taking illegal drugs. 4. Side effects may include: light-headedness, headache, dizziness, visual disturbances, amnesia, and nausea. In some people, oral sedation may not work as desired. 5. Smokers will probably notice a decrease in the medications ability to achieve desired results. 6. Do not eat anything six hours prior to your appointment. Clear liquids are best if you must drink before your visit, but keep to a minimum, (eg. water, apple juice). No grapefruit juice. If you are a diabetic please talk to the doctor about what you may consume to prevent a problem with your insulin or oral diabetic medication. 7. Nitrous oxide (laughing gas) may be used in conjunction with the dental sedation and local 8. On the way home from the dentist, your seat in the car should be in the reclined position. When at home, lie down with the head slightly elevated. Someone should stay with you for the next several hours because of possible disorientation and possible injury from falling. Do not drive for the rest of today. 9. Please call our office when you arrive home to confirm you are there and ask any questions you I understand these considerations and am willing to abide by the conditions stated above. I had an opportunity to ask questions and have had them answered to my satisfaction. Signed (patient) _________________________________ Signed (guardian, if patient under 18): ________________________________________ Escort Name: _____________________________________ Initial _________________ Medication given and dose___________________________________________

Source: http://www.smithrootcanal.com/download/oral_Sedation_Consent_Form.pdf