Patient Consent Form | Trillium Dental

Pre-Sedation Instructions

You will not be able to drive home. You must be accompanied by a responsible adult and may travel by private vehicle or taxi.
Do not eat or drink anything other than water for 8 hours prior to your appointment. Water may be taken up to 2 hours before your appointment.
Take all medications at their usual time with sips of water unless you have been instructed otherwise by your physician or dentist.
Wear loose comfortable clothing. Do not wear nail polish.
Report any health changes, prior to your appointment.

Post-Sedation Instructions

After your appointment, you must not operate a motor vehicle or hazardous machinery for at least 8 hours. You may be drowsy for the remainder of the day and should not consume alcohol and other drugs with sedative properties, provide care for small children or other dependents, or make important decisions.
Patient shall remain in the care of a responsible adult until patient is able to care for themselves safely.
Depending on your dental treatment, you may need to modify your diet. This will be reviewed with you prior to leaving the office.

If you have any concerns following the appointment, contact the office for advice.

I certify that I have had an opportunity to read, fully understand the terms and words with the above consent.

Consent

Select a Location*

Patient Type*

Name of Guardian*

Email Address*

Patient Name*

Date of Birth*

Phone*

By signing the consent section of this patient consent form, you agree that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance. Your information may be accessed by regulatory authorities under the terms of the Regulated Health Professions Act (RHPA) for the purposes of the Royal College of Dental Surgeons of Ontario fulfilling its mandate under the RHPA, and for the defense of a legal issue. Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of request is made, we will forward the information directly to you for review, and for your specific consent. When unusual requests are received, we will contact you for your permission to release the necessary information. We may also advise you if such a release is inappropriate. You may withdraw your consent for the use or disclosure of your personal information, and we will explain the ramifications of that decision and the process.

Signature*

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Date*