Procedural IV Sedation Informed Consent

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.

2. I understand that moderate IV procedural sedation is a drug-induced state of reduced awareness and decreased ability to respond. Moderate IV procedural sedation does not produce a state of sleep. I will be able to respond during the procedure. My ability to respond normally returns when the effects of the sedation wear off. 

3. I understand that there is a deposit required to schedule a Sedation appointment for my treatment. The deposit for appointments 2hrs and under is $250 and appointments 3 hours or more the deposit is $500

a. I understand that the deposit paid will be applied to any portion of the treatment that I am financially responsible for. If a credit remains after West GP Dental has received payment from my insurance company(s) I will be credited back by the method I used to pay for my deposit.

4. I understand that there are risks or limitations to all procedures. For sedation these include:

a. Inadequate sedation with initial dosage which may require patient to undergo the procedure without full sedation or to have the procedure another time. An additional dose or doses may be required to complete the procedure.

b. Atypical reaction to sedative drugs that may require emergency medical attention and/or hospitalization such as altered mental states, physical reactions, allergic reactions, and other sicknesses, including respiratory or cardiac arrest.

c. Inability to discuss treatment options with the doctor should circumstance requires a change in treatment plans.

5. If, during the procedure, a change in treatment is required, I authorize the doctor and the operative team to make whatever change they deem in their professional judgment is necessary. I understand that I have the right to designate the individual who will make such a decision.

6. The fees associated will be adjusted accordingly if during the procedure a change in treatment is required. We as an office are not always able to predict said changes prior to the procedure being completed. I accept this information and acknowledge responsibility of payment should such an instance occur.

7. I have had the opportunity to discuss the sedation and have my questions answered by qualified personnel including the doctor. I also understand that I must follow all the recommended treatments and instructions of my doctor. 

8. I understand that I must notify the doctor if I am pregnant, or if I am lactating. I must notify the doctor if I have sensitivity to any medication, of my present mental and physical condition, if I have recently consumed alcohol, and if I am presently on psychiatric mood-altering drugs or other medications.

9. You will need a ride to escort you to and from your appointment (TAXI’s or similar driving services will not be allowed as your ride). Your ride MUST accompany you to check in, as there will be specific instructions we must relay to them with regards to your care.  You cannot operate a motor vehicle or hazardous machinery for 24 hours after your IV Sedation appointment as you are legally impaired.

10. I acknowledge receiving a copy of the pre- and post-operative instructions, which have been explained to me. I understand all of the advice given to me by my dentist. After my discharge, I will notify my doctor and dentist if I experience any acute pain, heavy bleeding from the surgical site, respiratory problems, or any other post-operative problems.

I, the undersigned, certify that I have reviewed all this information and agree to all terms. 

For your safety, please follow the outlined pre-sedation instructions for your appointment very carefully. 

Food and Beverages

1. NO FOOD OR DRINK SHOULD BE TAKEN FOR A MINIMUM OF 8 HOURS BEFORE APPOINTMENT. A small amount of WATER can be taken with medications no more than 2 hours prior to scheduled appointment. Absolutely NO MILK products 

MEDICATIONS

1. It is essential to discuss with your dentist whether you should take medication(s) you otherwise take on

2. Under no circumstances should you continue the intake of the following types of medication unless otherwise discussed with your dentist prior to treatment.

(Marijuana, Anti-depressants, other psychotropic drugs etc.)

3. If you are a marijuana user we can not guarantee the sedation will take full affect
for you and all your treatment may not be completed. You must refrain from using
marijuana for as long as possible prior to your appointment. Should we not be able to
complete your treatment you will still be charged for the cost of sedation.

CLOTHING

1. Please remove nail polish from at least one fingernail on each hand.

2. ALL JEWELRY needs to be REMOVED - Including but not limited to, Tongue rings, lip rings etc. 

3. Female patients should wear loose/casual pants. (No Dresses or Skirts)

4. Wear loose casual clothing for your appointment (e.g., short sleeve t-shirt).

SMOKING

Refrain from smoking or vaping prior to treatment (Includes Marijuana and tobacco products)

WOMEN ONLY - BREASTFEEDING

1. If you are breastfeeding it is imperative that you build up a 48-hour supply prior to your IV sedation appointment.

2. Following your appointment, you will be asked to waste any breast milk you produce for the next 48 hours. 

TRANSPORTATION AND AFTER CARE

1. Under no conditions can you drive yourself home.

2. A responsible adult with a vested interest in your safety must accompany you home.

3. Rides must check in with patient upon arrival. (A taxi driver or similar service cannot be used as your escort) 

4. Depending on the treatment you are having completed your ride may be asked to collect your prescriptions while you are in your procedure.

5. It is recommended someone stays with you for up to 6 hours or longer if possible.

CHANGE IN HEALTH STATUS AND CANCELLATION POLICY

1. To cancel or change your appointment, 5 business days from your appointment date is required. If it is cancelled within those 5 business days, your deposit will be held, and an additional deposit will be required prior to rebooking.

2. If your general health deteriorates (e.g., cold, cough, fever, etc) it is imperative you contact the program coordinator 48 hours prior to the day of the appointment. If in doubt, please phone to report the change in your health status. 

FAILURE TO COMPLY

Should ANY of the sedation instructions fail to our standards, your treatment will be cancelled by the office and your deposit will be held. A new deposit of $250 will be required to rebook your appointment. THIS IS FOR YOUR SAFETY; NO EXCEPTIONS WILL BE MADE.

If you have any questions, please call our office at 780-833-8600. It is important that you understand the circumstances surrounding this treatment.