To the parent or legal Guardian of patient above:
You have the right, as a patient, to be informed about your condition and the recommended anesthesia to be used so that you may make the decision whether or not to receive the anesthesia after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the anesthesia.
I voluntarily request that anesthesia as indicated below be administered to the patient names above. I understand it will be administered by Dr Izadi. I understand that anesthesia involves additional risks and hazards but I request the use of anesthetics for the relief and protection from pain or anxiety during the planned procedures for the named special needs patient above. I realize the type of anesthesia for special needs patients may be any of listed types below and the anesthesiologist will need consent for all modalities and that other complications include but are not limited to the specific anesthesia method below:
GENERAL ANESTHESIA – Nausea, vomiting, mouth or throat pain, hoarseness, injury to vocal cords, teeth, lips, mouth or eyes, memory dysfunction/memory loss, permanent organ damage, brain damage, awareness during the procedure under anesthesia, injury to blood vessels, vomiting, aspiration, pneumonia, headache, shivering.
Intramuscular injection and/or Monitored Anesthesia Care (MAC) with sedation (Moederate to deep sedation)--An unconscious state, depressed breathing, injury to blood vessels, permanent organ damage, memory dysfunction/ memory loss, brain damage, nausea, vomiting, mouth or throat pain, hoarseness, injury to mouth or teeth, aspiration, pneumonia, headache, shivering, permanent organ damage, brain damage, potential to convert to a general anesthetic if the sedation is not adequate or in cases of emergencies.
I understand that no promises have been made to me as to the results of anesthesia methods.
If there are any questions please TEXT Dr Izadi at (703) 662-3166 or email Info@safedentalsedation.com and a time can be set up to talk.
I have also been given an opportunity to reach out regarding any questions about the anesthesia methods, the procedures to be used, the risks and hazards involved, and alternative forms of anesthesia. I believe that I have sufficient information to give this informed consent. I acknowledge that I have read this form or had it read to me, that I understand the risks, alternatives, and expected results of the anesthesia service and that I had ample time to ask questions and to consider my decisions.
I undestand that in the day if the procedure i must be available by phone should we need to reach out to you.
I understand that I must print my full name below, list my relationship to the patient, and to have a second person to witness me consenting to this form.