Alternative options to deep sedation/general anesthesia have been discussed with me and may include the use of local anesthesia with nitrous oxide sedation or local anesthesia alone.
All sedation and anesthesia patients must be accompanied to and from the appointment by a responsible adult. The responsible adult should remain in the office during the appointment unless authorized by the practitioner. For the safety of the patient, the responsible adult must remain in the designated waiting area during treatment time. Office staff will escort the responsible adult back to the treatment area once the anesthesiologist deems it is safe, to be present for recovery. Upon release, the patient must be driven home by the responsible adult (public transportation or cabs are not acceptable).
I confirm that myself/the patient has not had anything to eat (other than indicated medications with water) for at least seven (7) hours prior to anesthesia, and only clear fluids were consumed up to two (2) hours prior to anesthesia.
I certify that to the best of my knowledge, myself/the patient is not pregnant or trying to become pregnant.
I have read and agreed to the Notice of Privacy Practices/HIPAA agreement posted on our website www.bayanesthesiagroup.com.
I consent to the anesthesia deemed appropriate by my Dentist Anesthesiologist. I acknowedge that I have read this form or had it read to me and that I understand the risks, alternatives and expected results of the anesthetic plan of care.