INFORMATIONAL INFORMED CONSENT NITROUS OXIDE (N2O GAS) ADMINISTRATION

I UNDERSTAND that nitrous oxide, commonly called “laughing gas” or N2O, is used to provide relaxation or light-conscious sedation during dental procedures. I also understand that the administration of nitrous oxide, like all medications, carries certain risks, hazards, and potentially unpleasant side effects, which are infrequent but may occur nonetheless. I understand that I, or my legal dependent, will be fully awake, aware of my/their surroundings, able to obey commands, and respond to questions and instructions.

1. I have advised the doctor/staff of my medical history, and/or have updated them on any changes to my medical history, including, but not limited to: head colds, upper respiratory infections, breathing problems, asthma, lung disease, or any surgeries.

2. I understand local anesthetic will also be required for most dental procedures. Nitrous oxide sedation is administered to help reduce anxiety and apprehension, and does not block pain or discomfort.

3. I understand and accept nitrous oxide is an elective procedure and is not required for needed dental treatment, and additionally understand the possible complications associated with nitrous oxide, which include, but are not limited to:

1. Nausea and vomiting
2. Sluggishness in speech and movement
3. Tingling in the extremities, and possibly the entire body
4. Generalized warmth with possible flushing or blushing of the skin
5. Feeling of floating or dream-like state
6. Excessive perspiration which may lead to sweating and coldness with possible shivering

4. I understand nitrous oxide sedation is very effective for most people. However, some may develop unwanted or adverse reactions. If that should occur with my treatment, the dentist may decide to discontinue its use for my dental procedure.

5. I understand that nitrous oxide sedation may not produce the calming effect that I desire, and that I may require other sedative drugs for my procedure. If I elect additional sedative drugs or modalities for my anxiety, it may require another appointment to proceed with my needed dental care, and that additional charges may be required.

INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of nitrous oxide administration and have received answers to my satisfaction. I acknowledge that nitrous oxide use is an option and not absolutely necessary for dental treatment but, nevertheless, I accept this option. I do voluntarily assume any and all reasonable medical/dental risks, including the substantial and significant risk of serious harm, or even death, which may be associated with nitrous oxide administration in hopes of obtaining the potential desired relaxation or level of light conscious sedation. I acknowledge that planned treatment may be postponed or terminated if nitrous oxide administration does not provide the desired effect, and I acknowledge that no guarantees or promises have been made to me concerning the efficacy of nitrous oxide administration in my case or the case of my minor child or ward for whom I give consent for this procedure. The fees for nitrous oxide administration have been explained to me and are satisfactory. By signing this document I am freely giving my consent to allow and authorize Dr. Wahlen and/or his/her associates or agents to render oral sedation as deemed appropriate and/or advisable to my dental condition, including prescribing and administering appropriate anesthetics and/or medications.