NITROUS OXIDE INFORMED CONSENT FORM

Terence Q.L. Young, D.D.S. Airway-Focused Dental Care

3660 Waialae Avenue, Suite 212 Honolulu, HI 96814

PH 808.945.9977 FX 808.945.2210

admin@terenceyoungdds.com youngbreathandwellness.com

Patient Name

The purpose of this Informed Consent Form is to provide an opportunity for patients (and/or their parents or guardians) to understand and give permission for the use of Nitrous Oxide when provided along with dental treatment. Each item should be checked off after the patient (and/or parent or guardian) has had the opportunity for discussion and questions.

1 I accept and understand that Nitrous Oxide is commonly called laughing gas and provides relaxation although I will be awake fully conscious aware of my surroundings and able to respond rationally to inquires and directions

be awake, fully conscious, aware of my surroundings, and able to respond rationally to inquires and directions.

1. I accept and understand that Nitrous Oxide is commonly called laughing gas and provides relaxation, although I will

2 I accept and understand that the use of Nitrous Oxide is not required to provide the necessary dental care

3 I accept and understand that the purpose of Nitrous Oxide is to make it more comfortable for me to receive the necessary dental care with less pain andor anxiety I also accept and understand that the use of Nitrous Oxide has limitations and risks and absolute success cannot be guaranteed See also 5 below

4 I accept and understand that Nitrous Oxide will be administered by way of the inhalation route

5 I accept and understand that the alternatives to Nitrous Oxide are

--No Nitrous Oxide: The necessary procedure is performed under local anesthetic only.

--Anxiolysis: A pharmacologically induced state of consciousness where an individual is awake but has decreased anxiety to facilitate coping skills, retaining interactive ability.

--Oral Conscious Sedation: Sedation via pill form that will put me in a minimally depressed level of consciousness.

--Intravenous (IV) Sedation/General Anesthetic: Commonly called deep sedation or general, a patient under general anesthetic has no awareness and must have his/her breathing temporarily supported. General anesthesia is appropriate for more invasive procedures.

6 The use of Nitrous Oxide has been fully explained to me including all risks involved I have been fully informed that temporary complications may include but are not exclusive of tingling in the fingers toes cheeks lips tongue head or check area heaviness in the thighs andor legs followed by a lighter floating feeling resonation in the voice or presence of a hypernasal tone warm feeling throughout body with flushed cheeks fits of uncontrollable laughter or giddiness detachment or disassociation from environment may occur intense and uncomfortable warm andor hot feeling throughout body lightweight or floating sensation with an accompanying out of body sensation sluggishness in motion and slurring andor repetition of words feeling of nausea vomiting agitation andor hallucination All of these complications are temporary

to ask questions, and am fully satisfied with the answers I received.

7 I have had the opportunity to discuss Nitrous Oxide in conjunction with my dental care and have had an opportunity to ask questions and am fully satisfied with the answers I received

7. I have had the opportunity to discuss Nitrous Oxide in conjunction with my dental care, and have had an opportunity

8 I accept and understand that I must follow all recommended instructions

9 I have informed the doctor of my complete medical history including any recent surgeries or changes in my medical history involving lung respiratory ear infection or common cold I also accept and understand that I must notify the doctor of my present mental and physical condition

10 I accept and understand that I must notify the doctor if I 1 am pregnant 2 have sensitivity to any medication 3 have recently consumed alcohol andor 4 am presently on psychiatric mood altering drugs or other medications

have recently consumed alcohol, and/or (4) am presently on psychiatric mood altering drugs or other medications.

10. I accept and understand that I must notify the doctor if I: (1) am pregnant, (2) have sensitivity to any medication, (3)

I hereby authorize treatment and agree to pay all related professional fees. Fees not covered by my insurance will be promptly paid upon notification from this office. I have read and understand this document in its entirety, outlining office policies and financial policies of Dr. Terence Young. Without any reservations, I agree to abide by the policies outlined herein. Form Completed By:

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NITROUS OXIDE INFORMED CONSENT FORM

DOB

CONSENT AND AUTHORIZATION