Consent for IV Sedation Form

Informed Consent for Intravenous Sedation

I have elected to proceed with intravenous sedation in conjunction with my dental treatment.

Purpose of Intravenous Sedation:

I understand that the purpose of intravenous sedation is to more comfortably receive necessary dental care. I understand that intravenous sedation is a drug-induced state of reduced awareness and decreased ability to respond but that it does not produce a state of sleep.

Risk and Complications of Intravenous Sedation:

I have been informed of, and understand, that while intravenous sedation is considered safe, potential risks associated with anesthesia include, but are not limited to:

  • Allergic or adverse reactions to medications or materials;
  • Pain, swelling, redness, irritation, numbness and/or bruising in the area where the IV needle is placed (phlebitis) which may cause prolonged discomfort and/or disability, and may require special care. Usually the numbness or pain goes away, but in some cases may be permanent;
  • Nausea, vomiting, disorientation, confusion, lack of coordination, and occasionally prolonged drowsiness.
  • Some patients may have awareness of some or all of the events of the cleaning or surgical procedure after it is over.
  • A remote possibility of complications that would require transportation to a hospital for treatment and could lead to brain damage, stroke, heart attack, coma, or death.

Patient's Responsibilities:

I understand that I am an important member of the treatment team. In order to increase the chance of achieving optimal results, I have provided an accurate and complete medical history, including all past and present dental and medical conditions, prescription and non-prescription medications, allergies, recreational drug, tobacco and alcohol use, and pregnancy/lactation (if applicable).

I understand that I must have an empty stomach, and I have followed the fasting guidelines as outlined for my case. I understand that doing otherwise may be life- threatening. If instructed, I have taken my regular medications and/or medicine given to me by my doctor using only small sips of water. I am accompanied by a responsible adult to drive me to and from the office and he/she will stay with me after the procedure until I am recovered sufficiently to care for myself.

I understand the drugs given to me for this procedure may not wear off for 24 hours. I understand it is my responsibility to refrain from driving a motor vehicle, operating hazardous machinery, and making legal or financial decisions for at least 18 hours after the procedure while I am recovering from the anaesthesia.

I had sufficient time to read this document, understand the statements, and have had a chance to get all my questions answered. By signing this document, I acknowledge and accept the possible risks and complications of intravenous sedation and agree to proceed.

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