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Menu
Who We Are
Our Clinic
Our Team
Dr. Jagatjit Dhillon
Dr. Amardeep Gill
Dr. Do Sung
Our Forms
New Patient Form
X-Ray Release Form
How We Can Help?
Maintaining A Healthy Smile
How Can I Sleep Better?
Fill Your Cavities
Replacing Missing Teeth
Children’s Dentistry
Restoring your smile
Protect Cracked Teeth
Control Gum Disease
Straighten Your Crooked Teeth
Services We Provide
Orthodontics
Invisalign
Braces
Myobrace
30 Second Smile Test
General Dentistry
Exam
Hygiene
Fillings
TMJ Treatment
Patient Scanning
Teeth Whitening
Emergency Dentistry
Dental Hygiene
Periodontal Health
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Oral Sedation Consent Form
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CONSENT TO CONSCIOUS ORAL SEDATION FOR RESTORATIVE AND ORAL SURGERY
Consent
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I understand that the purpose of conscious sedation is to more comfortably receive the necessary dental care. I understand that conscious sedation is not required to provide the necessary dental care. I understand that conscious sedation has limitations and risks, and absolute success of treatment cannot be guaranteed.
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Consent
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I understand that conscious sedation is a medically-induced state of awareness, but that conscious sedation does not produce a state of sleep. I understand that I will retain a decreased ability to respond during the procedure, and that my ability to respond normally returns when the effects of sedation wear off.
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Consent
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If, during the procedure, a change in treatment is required, I authorize the dentist and the operative team to make whatever change they deem in their professional judgement is necessary. I understand that I also have the right to designate an individual who will make such a decision on my behalf.
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Consent
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I understand that there are risks and limitations to all dental procedures. For conscious sedation, these include:
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Consent
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A. Inadequate sedation with initial dosage, which may require the patient to undergo the procedure without full sedation, or require delaying the procedure.
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Consent
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B. Atypical reaction to sedative drugs which may require emergency medical attention and/or hospitalization, including physical reaction, altered mental state, allergic reaction, illness or other condition.
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Consent
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C. Inability to discuss treatment options with the doctor while sedated, should circumstances require a change in treatment plan.
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My obligations for Conscious Oral Sedation:
Obligations
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I will need to have arrangements made for someone to drive me to and from my dental appointment. I will not be able to drive or operate machinery, or make important decisions such as signing documents, for 24 hours after my procedure.
Obligations
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I understand that I must notify the dentist if I am pregnant, have sensitivity to any medication, have recently consumed alcohol, or if I am presently on psychiatric mood-altering drugs or other medications. I must notify the dentist of any concerns with my present mental or physical condition.
Obligations
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I must have a completely empty stomach before undergoing the procedure.
IT IS VITAL THAT I HAVE NOTHING TO EAT OR DRINK FOR EIGHT (8) HOURS PRIOR TO ORAL SEDATION. Regularly taken medications can be taken with water only.
I have read and understood the risks and complications which may occur in connection with this procedure. I understand that the potential risks are not limited to those described above. I agree that I have been given and understood enough information to give my consent for the above procedure and to any other treatment or service deemed necessary or advisable. I have had the opportunity to ask questions and all such questions have been answered to my satisfaction. I have given a full and accurate report of my medical history, including allergies, conditions, medications and history of illness. I authorize and agree to undergo the procedure.
Today's Date
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DD slash MM slash YYYY
Name
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First Name
Last Name
Patient/Guardian Signature
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Treatment Provided by:
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Dr. Jagatjit Dhillon
Dr. Do Sung
Dr. Amardeep Gill
Dr. Jennifer Yu
Height
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Weight
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