Oral Sedation is provided to minimize anxiety and reduce restlessness during extensive dental procedures. It is safe, effective and its effect diminishes soon after the procedure has been completed. It is imperative however that the protocol described in this document be closely followed.

1. Please read and ask any questions, understand and sign this form prior to taking your pre-operative medication. You are unable to give informed consent while medicated and your procedure will not be performed without your valid, informed consent.
2. Because this medication is mildly sedating, it effects judgement and response time, and will make you sleepy. Therefore use of this medication in conjunction with dental treatment requires you to be escorted from your appointment. You will need to arrange a responsible adult escort and confirm with them well in advance of your appointment.
3. You will be required to be present in the office 1 hour prior to your scheduled appointment time to have the sedation medication administered (this appointment time will have already been made when scheduling your appointment that requires the sedation).
4. Because the effect of this medication continues for an indeterminate period after treatment, driving or operating of any heavy equipment is prohibited for a period of 12 hours after administration of this medication. Please avoid ingesting any grapefruit products as it can seriously affect how the medication works.
5. Oral Sedatives should not be ingested if you are pregnant, or breast-feeding. They should not be taken if you have kidney, liver disease or untreated narrow glaucoma, if you are hypersensitive to benzodiazepines (Valium, Ativan, Versed, etc.) or are taking any medication which adversely interacts or amplifies the effects of these medications.
6. Please do NOT eat anything or ingest any fluids during the six hours immediately prior to the dental appointment. If you do so, it will limit the effectiveness of the medication
7. Please continue to take any prescription medications, prescribed by your physician, as you normally would on the day of the dental appointment. You are permitted to take these medications with water.
8. Do NOT drink alcohol or administer recreational drugs on the day of the administration of the sedative medication, as this can intensify the effect or lead to adverse effects.
9. After your procedure you will remain mildly sedated and should rest, you will need to remain in the care of a responsible adult, as you may be unsteady and could become disoriented. Some side effects of the medication can result in headaches, dizziness, memory loss, or drowsiness lasting until the next day.
10. Please dress comfortably, and you may decide to bring headphones to listen to music or watch a movie on our TV system as you wait for the sedation to set in.

I understand that conscious sedation is a drug induced state of reduced awareness and decreased ability to respond. Conscious sedation is not sleep. I will be able to respond. My ability to respond normally returns when the effects of the sedative wear off.

I will tell the doctor ALL medications (this includes prescription and nonprescription as well as multivitamins and herbal supplements) that I am taking as they can adversely interact with the sedation medications.

My signature affirms that I understand these instructions and am willing to abide by the conditions described in this document. I have had the opportunity to ask questions, and have had them answered to my satisfaction. I consent to Conscious Sedation in conjunction with my dental care.