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.

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.