I consent to the procedure(s) noted above being performed on me. I acknowledge that the procedure(s) its implications, and possible complications have been explained to me, along with the alternatives, including not having any treatment. I understand the procedure will entail moderate IV sedation and I consent to the administration of this sedation by the above-named practitioner. I also understand that during the course of any treatment, unforeseen circumstances may arise that could necessitate or make it advisable for an additional or alternative procedure to be performed, which I also consent to being performed on me. Should there be discovery of additional cavities that were not previously diagnosed that could affect my oral health, I consent to having alternate or additional procedures performed to remove the newly discovered decay.
The purpose of this document is to provide an opportunity for patients to understand and give permission for moderate IV procedural sedation when provided along with dental treatment. Each item should be initialed after the patient has the opportunity for discussion and questions.
1. I understand that the purpose of sedation is to receive necessary care more comfortably. Moderate IV procedural sedation is not required to provide the necessary dental care. I understand that moderate IV procedural sedation has limitations and risks and absolute success cannot be guaranteed.