Oral Conscious Sedation Consent Form

The purpose of this document is to ensure that you understand oral conscious sedation and consent to its use during your dental procedure.

Oral Conscious Sedation utilizes the elective administration of an oral sedative medication during a dental procedure to reduce the fear and anxiety related to the experience. It does not put a person to sleep. Properties of oral sedatives have allowed many patients to receive dental treatment in a safe and relaxed environment. The benefits of conscious sedation include reduced awareness of unpleasant sights, sounds and sensations along with reduced anxiety. Like all medications, oral sedatives have limitations and risks and absolute success of treatment is variable and cannot be guaranteed. To make the process of conscious sedation more effective, we can combine it with Nitrous Oxide-Oxygen (commonly called ‘Laughing Gas’).

Eligibility for treatment with oral sedatives with or without Nitrous oxide-Oxygen is determined through information gathered during a consultation and screening appointment. While many individuals will qualify for oral conscious sedation, not all people are candidates for it. If such a situation presents itself then the doctor will discuss appropriate treatment options.

I understand that the alternatives to Oral Conscious Sedation are:

No sedation. I may choose to have the dental procedure performed under local anesthetic only.
Nitrous oxide Sedation: I may choose to have the dental procedure performed under Nitrous oxide (Laughing Gas).

Anxiolysis: I may choose to have the necessary procedure performed by taking a pill to reduce anxiety and fear
IV Sedation: Intravenous sedation involves administration of a sedative agent through a vein and can be provided by an Anesthesiologist or an Oral Surgeon. (Not provided in our facility)

I have been informed and fully understand that like all medications, oral sedatives, have a potential to cause adverse reactions, side effects, and anaphylaxis. I understand that sedation will alter my sense of judgement, reaction time and work performance, so I should plan accordingly.

I understand that with oral conscious sedation I may experience relaxation or drowsiness, a reduced sense of fear or anxiety, altered perception of time, tingling sensation, dizziness or light headedness, unsteadiness, nausea, and hallucinations or dreams. Less common side effects include blurred vision, transient memory loss, or ‘rebound insomnia’ for several days. Rare side effects include agitation, behavior changes, convulsions, hypotension, skin rash, itching, sore throat, fever, chills, unusual tiredness, increased heart rate, hyperactivity or weakness may occur.

I understand that unforeseen circumstances may arise that might necessitate making a decision regarding my treatment to achieve my ultimate treatment goals. As I will be unable to make these decisions under sedation I understand that I have the right to designate an individual to do it on my behalf. If I do not designate anyone, I authorize Dr. Anand or Dr. Rawat to use their professional judgement in making decisions, considering my health-related, functional and esthetic objectives set out in my treatment plan.

I understand that I will not be able to drive or operate machinery while on oral sedatives and for 24 hrs afterwards. Therefore, I will have to make arrangements for someone to drive me to and from my dental appointment. The designated person should be at least 18 yrs. or older.

I have provided the most accurate information to the doctor regarding my medical history, medications (including supplements), allergies and other pertinent information. I will follow all pre- and post-treatment instructions provided. I am aware that the practice of dentistry is not an exact science and that no guarantees have been made to me concerning the results of the treatment.