Morpheus Dental Sedation Online Consent Form

Welcome To Morpheus Dental Sedation

We are pleased to assist you on your dental journey and are committed to providing a calm and comfortable experience.

Please read this information carefully to understand what to expect during your sedation. If you have any questions, feel free to contact us.

The form should take approximately 10-15 minutes to complete.

Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Email*
example@example.com
Phone Number*
What is the name of the Practice (and City) where you will be receiving treatment?
What is the Date of your appointment?

Please press NEXT to continue the rest of the consent process.

Important Reminders:

• Bring a responsible adult with you who has signed the consent form. While they
do not need to stay for the entire appointment, they must be reachable by phone.
Ideally, we would meet them before beginning your treatment.

• Plan for rest. Do not schedule any important tasks or responsibilities for the
remainder of the day after your appointment.

• Provide accurate medical history. It is essential to disclose all medications and
any recreational drug use, as these can impact your sedation. We are nonjudgmental but require full transparency for your safety.

• Relax! Our goal is to make your experience as smooth and stress-free as possible.

If you have any queries at all about the sedation, please get in touch and we’ll be
sure to answer any questions you may have and put your mind at ease.

Medical History Form

Although dental personnel primarily treat the area in and around your mouth, your
mouth is part of your entire body.

Health problems that you may have or medications that you may be taking could, have an important interrelationship with the dentistry you will receive.

Please answer the following questions as honestly as possible.

Tick appropriate box and please list and further details in the
space provided.

Have you ever had IV Sedation before? If so, please give details below*

YesNo
Details:

Are you undergoing any doctor or hospital treatment at the moment?*

YesNo
Details:

Do you have any allergies? If so please give details below*

YesNo
Details:

Do you suffer from Sleep Apnoea?If so, do you have a CPAP machine? (you will need to bring this with you)*

YesNo
Details:

Do you regularly take Cannabis or any other recreational drug? (Please answer honestly, cannabis use affects the efficiency of certain sedation drugs)*

YesNo
Details:

Do you have any Chronic Health Condition that requires regular medication?*

YesNo
Details:

Do you take medication for Depression / Stress / Anxiety?*

YesNo
Details:

Have you ever had a problem following Sedation, General or Local Anaesthetic (in dental setting or in hospital)?*

YesNo
Details:

Is there a possibility you may be Pregnant?*

YesNo
If yes, how many weeks/months?

Are you currently breastfeeding?*

YesNo

Do you drink alcohol?*

YesNo
If yes, how many units per week?
Examples of unit measurements:

A pint of average-strength (4% ABV) lager contains about 2 units.

A single measure (25ml) of spirits (40% ABV) is 1 unit.

A 125ml glass of typical-strength champagne has around 1.5 units.

A standard glass (175ml) of Red Wine has around 2 units.

Please enter your Height*
Please enter your Weight*

Have you ever had any serious illness not previously discussed?*

YesNo
Details

Please list any regular medications you take below:

Sign Medical History Form
“I have answered the questions above honestly and to the best of my knowledge.
I understand that providing incorrect information may affect my treatment and
safety. I understand that it is my responsibility to inform the dental practice of any
changed in medical status.”
Name:*
Date of Birth:*
Signature*

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Consent for Conscious Intravenous Sedation

Understanding IV Sedation

You have chosen IV Conscious Sedation for your dental treatment. This method keeps vyou awake but deeply relaxed. While you may not recall much of the procedure, your protective reflexes will remain active.

• Primary medication: Midazolam.

• Additional medications (if required): Remimazolam (alternative to Midazolam),
Paracetamol, and Dexamethasone (to manage pain and swelling).

• You will not be completely asleep, but deeply relaxed. This is not a general
anaesthetic.

Possible Risks:

• Bruising or tenderness at the site where the cannula is placed (moderate risk)

• Nausea and vomiting (low risk)

• Slower breathing (low risk)

• Rare complications requiring hospital care (low risk)

Alternatives to IV Sedation:

• Local anaesthetic only

• Relative analgesia (gas and air – requires referral)

• General anaesthesia (hospital-based, requires referral)

IV Sedation Pre-Treatment Instructions

Before Your IV Sedation Appointment

Please read these instructions carefully. They are essential for your safety and comfort.

Failure to follow them may result in your procedure being delayed or cancelled.

Do:
- Drink clear fluids such as water, squash, or clear juice up to 2 hours before your appointment to stay hydrated.
- Stop eating solid food at least 6 hours before your appointment.
  Take regular prescribed medication as advised by your dentist or doctor (unless told otherwise).
- Wear comfortable, loose-fitting clothing with short sleeves or sleeves that roll up easily for IV access.
- Bring a list of all medications you are currently taking.
- Arrange for a responsible adult (aged 18 or over) to take you to and from your appointment and stay with you for 24 hours afterward.
Do not:
- Eat or drink anything except clear fluids in the 6 hours before your appointment.
- Consume alcohol, caffeine, or recreational drugs for 24 hours before your appointment.
- Take Co-codamol, Codeine, Tramadol, or any other strong painkillers, sedatives, or sleeping tablets for 24 hours before and after your treatment unless your dentist or doctor has advised otherwise.
This includes medicines such as:
- Diazepam, Lorazepam, Temazepam (for anxiety or sleep)
- Zopiclone, Zolpidem (sleeping tablets)
- Pregabalin, Gabapentin (nerve pain medications)
- Strong opioids such as Morphine, Oxycodone, or Fentanyl
Do Not:
- Smoke or vape for at least 12 hours before your appointment, as nicotine can affect oxygen levels and sedation response.
- Wear jewellery, nail polish, or false nails, as these can interfere with monitoring equipment.
- Drive, operate machinery, sign legal documents, or make important decisions for 24 hours after sedation.
Inform your dentist immediately if:
- You develop a cold, flu, chest infection, or new illness before your appointment.
  You are pregnant, breastfeeding, or think you might be.
- You have diabetes, sleep apnoea, or any changes to your medical history or medication.
After your appointment:
- Rest quietly at home for the remainder of the day.
- Eat light, easy-to-digest food once you feel ready.
- Continue to avoid alcohol, recreational drugs, and sedative medication for 24 hours.
Your escort must stay with you until the following day.

IV Sedation Post-Treatment Instructions:

• A responsible adult must stay with you for the first 24 hours after the procedure
- have them accompany you if you will be using any stairs.

• Avoid Co-codamol, Codeine and Tramadol for the next 24 hours.

• Do not drive, operate heavy machinery, or engage in activities requiring
coordination, focus, or judgment such as signing important documents for at least
24 hours after sedation.

• A responsible person should accompany you home afterwards - do not get a taxi by yourself or take public transport.

• You may experience drowsiness, dizziness, or forgetfulness after the procedure
and should subside within 24 hours - take it easy and rest after the treatment.

• You may experience mild bruising or tenderness at the IV site and should resolve
in a few days.

• Drink plenty of fluids to stay hydrated, but avoid alcohol, caffeinated or
carbonated drinks for 24 hours.

Contact your dental clinic if you have any concerns following your treatment.

Consent Agreement
“I confirm that I understand the sedation procedure, risks, and alternatives. I consent to the administration of IV sedation by my sedationist.

I acknowledge that my treatment may need to be modified based on clinical findings during the procedure, except for tooth removal, which will only be done with prior consent.

I agree to settle the payment before sedation begins.

I certify and acknowledge that I have read this form, that I understand the risks,
alternatives and expected results of the anaesthesia service and that all of my questions have been answered fully to my satisfaction.

I understand the treatment that I am having done today, I have had the risks explained to me and the alternative treatments I could have, to my satisfaction.”
Name:*
Date of Birth:*
Signature*

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Please complete this next section and tell us how anxious you get, if at all, during your dental visits.

If you went to your dentist for treatment tomorrow, how would you feel?*

Not AnxiousSlightly AnxiousFairly AnxiousVery AnxiousExtremely Anxious

If you were sitting in the waiting room (waiting for treatment), how would you feel?*

Not AnxiousSlightly AnxiousFairly AnxiousVery AnxiousExtremely Anxious

If you were about to have a tooth drilled, how would you feel?*

Not AnxiousSlightly AnxiousFairly AnxiousVery AnxiousExtremely Anxious

If you were about to have your teeth scaled and polished, how would you feel?*

Not AnxiousSlightly AnxiousFairly AnxiousVery AnxiousExtremely Anxious

If you were about to have a local anaesthetic injection in your gum, how would you feel?*

Not AnxiousSlightly AnxiousFairly AnxiousVery AnxiousExtremely Anxious

Instructions for Responsible Adult (Escort)

Your escort must follow these guidelines to ensure your safety.

After IV Sedation:

• No alcohol until the next day.

• Walk with the patient using the crook of your elbow for support.

• Assist with stairs. Walk behind them when ascending.

• Avoid important discussions or signing documents – the patient may not
remember them.

• No operating machinery, cooking, or handling hot objects.

• Do not let the patient go outside alone.

• The patient should rest in a safe and supervised space (e.g., on a sofa in front of
the TV).

“I confirm that I have read and understood the post-sedation care instructions.”
Escort Name:*
Relationship to patient:*
Escort Contact number:*
I confirm that I will share this information with my escort*

YesNo (You, the patient, are responsible for making them aware of their duties prior to attending your appointment)

Please click SUBMIT below.

You will then be required to sign off on the consent form.

This consent form aims to make you fully informed and prepared for your sedation
experience.

If you have any concerns, please contact our team before your
appointment.

hello@morpheusdentalsedation.co.uk

Kind Regards,

Morpheus Dental Sedation
Should be Empty:

Sign Medical History Form

Consent Agreement