Informed Consent for Nitrous Oxide/Oxygen Conscious Sedation

Patient Name*
Date of Birth*

MonthDayYear
Informed Consent for Nitrous Oxide/Oxygen Conscious Sedation
I. Recommended Treatment

I hereby give consent to Dr. Alex Mercado to perform recommended treatment and any such additional procedure(s) as may be considered necessary for my well being based on findings made during the course of the recommended treatment. The nature and purpose of the Recommended Treatment have been explained to me and no guarantee has been made or implied as to the result or cure. I have been given satisfactory answers to all of my questions, and I wish to proceed with the Recommended Treatment. I also consent to the administration of local anesthesia during the performance of the Recommended Treatment.

II. Treatment Alternatives

Alternative methods of treatment have been thoroughly explained during my exam. All of the risks, benefits and options have been provided, but I wish to proceed with the recommended treatment described above.
III. 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
Signature:*

Patient/Parent/Guardian Clear
Date:*

MonthDayYear
Relationship (if patient a minor):
Witness (signature):

Clear
Should be Empty:

Informed Consent for Nitrous Oxide/Oxygen Conscious Sedation

III. Risks and Complications