Nitrous Oxide

Nitrous OxideI, understand and give permission for Apple Tree Dentistry to administer nitrous oxide conscious sedation. I understand that the administration of medication and conscious sedation with nitrous oxide carries certain common risks, hazards and side effects which are infrequent but nonetheless may occur.

They include but are not limited to the following:

1.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 or assistant that you are experiencing some discomfort.

2. Excessive perspiration- a flushed red feeling.

3. Behavioural problems- some patients experience vivid dreams or thoughts.

4. Shivering- usually at the end of the procedure

5. Inability to drive a motor vehicle at the end of the appointment – you may not feel comfortable or capable of driving after nitrous oxide sedation. If this occurs we will keep you under supervision until you feel better or have a drive home.

The benefits one can expect from nitrous oxide conscious sedation includes:

1.     Relief of anxiety

2.     Relief of gagging

3.     Pain control

4.     Overall stress reduction

Medical History:

1.     If there are any changes to your medical history please update with the doctor or assistant.

2.     If you have had any recent eye surgery within 3 months please inform us- ex. Vitreoretinal

Cost: Nitrous oxide cost to insurance must be submitted with an estimate. If you decide to use nitrous oxide before estimate has been sent you are responsible for the cost that may or may not be covered through your insurance.

I {patientName} (patient or parent) hereby acknowledge that I have been informed to my satisfaction of all the treatment considerations, including benefits of treatment, risks of treatment and risk of non treatment.  I {patientName} agree to this treatment and understand all risks and steps toward a succesful treatment plan, and I now consent to treatment.