Hanson Informed Consent for Nitrous Oxide/Oxygen Conscious Sedation

Patient's Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Responsible Party

Self Parent/Guardian
Responsible Party's Name *

First Name Middle Name Last Name
Patient's Email *

Confirmation Email example@example.com
Recommended Treatment
I hereby give consent to to perform Nitrous
Oxide/Oxygen Conscious Sedation procedure(s) on me or my dependent. Nitrous Oxide Sedation is commonly called a laughing gas and provides relaxation. I understand that I (or my dependent) will be awake, fully conscious, aware of my surroundings, and able to respond rationally to questions and directions during the Recommended Treatment. The Recommended Treatment is used for anxiety and pain control, as well as control of gagging. Local anesthesia will also be required for most procedures. The nature and purpose of the Recommended Treatment have been explained to me and no guarantee has been made or implied as to result or efficacy. I have been given satisfactory answers to all of my questions, and I wish to proceed with the Recommended Treatment.
Treatment Alternatives
Alternative methods of treatment have been explained to me but I wish to proceed with the Recommended Treatment described above.
Risks and Complications
I understand that there are risks and complications associated with the administration
of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:
1. Nausea and vomiting.
2. Temporary tingling in the fingers, toes, cheeks, lips, tongue, and head or neck
  area.
3. Temporary warm feeling throughout the body with accompanying
  flushing/blushing.
4. Temporary detachment or “out of body” sensation.
5. Temporary sluggishness in motion and/or speech.
6. Shivering (usually at the end of the procedure).
7. As a result of the injection or use of anesthesia, there may be swelling, jaw
  muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws, and/or facial tissues, which is typically temporary, but in rare instances, may be
  permanent.
Patient's Signature *

Clear
Patient's Name

First Name Middle Name Last Name
Responsible Party's Signature *

Clear
Responsible Party's Name

First Name Middle Name Last Name
Date

Month Day Year
Date
Hour Minutes AM/PM Option
Should be Empty:

Recommended Treatment

Treatment Alternatives

Risks and Complications