Oral Sedation Consent Form

Oral sedation is made available by this office to assist in minimizing anxiety that may be associated with going to the dentist. The intent of oral sedatives is to relax you, yet enable you to communicate with the dentist while undergoing treatment. Even though oral sedation in safe, effective and generally free of complications, by reading and signing this form you acknowledge that you are aware of possible risks of oral sedation, acknowledge these risks, and consent to and accept that option of receiving oral sedation.

Please initial each paragraph after reading. If you have any questions, please ask your doctor before initialing.

I acknowledge that I have read and signed this informed consent form prior to my taking any form of oral sedation. I acknowledge that some oral sedatives are generally prescribed as sleeping pills but are safely used in conjunction with dental procedures to decrease anxiety.*

I agree NOT to drive to and from the office after taking any sedative medication and I understand that I am responsible for arranging my own transportation to and from the dental office. I also agree not to drive or operate any machinery of the remainder of the day of treatment. I agree to have someone stay with me for several hours after sedation due to possible disorientation and to prevent possible injury from falling due to disorientation, loss of balance, etc.*

I agree to inform the office and refrain from undergoing oral sedation if the following conditions are present:Hypersensitivity to benzodiazepine drugs (Valium, Ativan, Versed)Pregnant or nursingLiver and kidney disease*

I have disclosed to the dentist that I am taking any of the following drugs that may adversely react with oral sedative: alcohol; any recreational/illicit drugs, nefazodone (serzone), cimetidine (tagamet, Tagamet HB, novocimetine, peptol); levodopa (dopar, or loradopa) for Parkinson’s disease; antihistamines such as Benadryl or tayist; verapamil (calan); ditiazem, (caeizem); erythromycin and azol antimyotic class of drugs (diazin, nixoral, or sporanox); HIV treatment drugs (indinavir and nelfinovar).*

Side effect may include light-headedness, headache, dizziness, visual disturbances, amnesia, nausea, or allergic reactions. Rarely, these side effects may require medical attention or hospitalization. With some patients, especially smokers, oral sedatives do not provide the desired antianxiety effects; therefore, planned dental procedures may need to be postponed or terminated.*

Complications may ensue if instructions of not eating or drinking for a specified interval prior to the dental appointment and not followed*

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