I hereby give permission for Dr. Knag, Dr. Moon and staff to perform nitrous oxide sedation.
I understand that the administration of medication and the performance of conscious sedation with nitrous oxide carries certain hazards, risks, and potential unpleasant side effects which are infrequent, but nonetheless, may occur. They include but are not limited to the following:
1. Excessive Perspiration: Sweating may occur during the procedure and you may become somewhat flushed during administration of nitrous oxide.
2. Expectoration: Removal of secretions may be difficult but can be controlled by use of suction tip.
3. Behavioral Problems: Some patients will talk excessively. You may become difficult to treat because you are so talkative, or experience vivid dreams; associated with physical movement of the body.
4. Shivering: Although not common, shivering can be quite uncomfortable. Shivering usually develops at the end of the sedative procedure when the nitrous oxide has been terminated.
5. Nausea and Vomiting: This is the most frequent of the side effects of nitrous oxide sedation but its frequency is still quite low. It is important to tell the doctor, hygienist, or assistant that you are experience some discomfort. The level of nitrous oxide can be adjusted to eliminate this side effect.
6. Driving a Motor Vehicle: You may not feel capable of driving after nitrous oxide. If this occurs, we will keep you until you feel better or have you call a friend or cab to insure your safety.
7. I have informed the doctor of my complete medical history including any recent surgeries or changes in my medical history involving lung or COPD, respiratory, ear infection or common cold. I also accept and understand that I must notify the doctor of my present mental and physical condition.
8. 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, (4) am undergoing cancer treatment with bleomycin sulfate, (5) have been diagnosed with methlenetetrahydrofolate reductase deficiency (MTHFR) and/or (6) am presently on psychiatric mood altering drugs or other medications.
I have been advised of alternative treatment, the benefits and risks which include but are not limited to: Fear and anxiety of the dental experience and/or avoidance of future dental appointments. These fears and anxiety, if not diminished by the use of nitrous oxide sedation, may precipitate other medical problems including minting, palpitation and other heart-related disorders.
The benefits one can expect from nitrous oxide sedation include: Help with anxiety and pain, gagging and medically compromised individual.
I hereby certify that I understand this authorization and the reasons for the above named sedative procedure and associated risks. I am aware that the practice of dentistry is not an exact science. I acknowledge that every effort will be made in my behalf for a positive outcome from sedation, but no guarantees have been made to the result of the procedure authorized above.