Informed Consent/Agreement Between Parties

The form is intended to be written in plain English. If you do not understand any part of it, please ask for an explanation.

Consent for the administration of Anesthesis
I understand that one or more of the following types of anesthesia may be used: General Anesthesia, Deep Sedation, Moderate Sedation, Mild Sedation, Local Anesthesia.

Significant risks and complications of anesthesia to be administered have been explained and include but are not limited to: sore throat, nausea and vomiting, dysphoria, upper respiratory infection, bronchitis, pneumonia, broken/chipped teeth, cardiac arrhythmia, cardiac arrest, allergic reaction, and death.

It is usually necessary for intravenous access to be established for sedation. U understand that multiple attempts at multiple locations on the body may be necessary to gain this access and that these attempts may cause bruising that is unsightly and uncomfortable.

I understand that the method used to apply monitors to the patient, position the patient, and to maintain the patient’s airway patent may result in red marks and/or bruising on the patient's head, face, neck, and body.

I accept these risks and hereby consent to the administration of anesthetics. No warranty or guarantee has been made as to the results thereof.

Following surgery, a responsible person will drive the patient home. I have made arrangements for this. I realize that impairment of full mental alertness and physical coordination may persist for up to 12 hours, and I will avoid making decisions or taking part in activities, which depend upon full concentration, judgment, or coordination during this period.

Consent to Transfer
I understand that all procedures to be performed will be done on an outpatient basis and that 24-hour patient care will not be provided. If my dentist anesthesiologist shall find it necessary or advisable to transfer the patient to a hospital or other health care facility, I consent and authorize my dentist anesthesiologist to arrange for and affect the transfer.

I further consent to the release of patient information pertaining to medical care should admission to an acute care facility become necessary during or following treatment received by my dentist anesthesiologist. I authorize medical records from the admitting acute care facility to be released to my dentist anesthesiologist.

Consent to Blood and/or Blood Products Transfusions
I understand that should the patient need blood or blood products, the patient will be transferred to an acute care hospital for the delivery of such.

Consent to Resuscitation
This signed document implies consent for resuscitation and transfers to a higher level of care should the patient suffer a cardiac or respiratory arrest or other life-threatening situation. I am aware that my dentist anesthesiologist does not honor “Do Not Resuscitate” (DNR) orders/

Photographic Consent
I consent to the use of photography (still and/or video images) of the procedures performed during the appointment.

Consent to Test for Blood-Borne Diseases
I understand that it may be necessary to test the patient’s blood in an effort to protect against possible transmission of blood-borne diseases/ If, for example, another person is stuck by a needle after giving an injection, I understand that the patient’s blood, as well as the other person’s blood, may be tested.

Preoperative and Postoperative Instructions
I have received and understand the Preoperative Instructions Form and Postoperative Instructions Form provided by Bryan Horgan, DDS. I agree to comply with all instructions provided by these forms.

Health History Questionnaire
I have read and completed the Health History Questionnaire and confirm that the information on this questionnaire is accurate to the best of my knowledge, and I am aware that withholding any information could result in injury or death.

Patient Valuables/Personal Property
I understand that Bryan Horgan, DDS shall not be liable for the loss or damage to any money and/or valuables.

Legal Relationship Between Dental Office and Dentist Anesthesiologist
I understand that Brayn Horgan is not an employee of the dental office in which I receive treatment.

Certification
I confirm that I have read and understand this informed ConsentAgreement Between Parties and that I am able to give legal consent for the patient