- DO NOT EAT or DRINK anything 2 hours prior to appointment
- Any personal illness, weakness, or known susceptibility must be reported; also, details of drugs recently prescribed or being taken especially sleeping drugs, tranquilizers, or cortisone preparations must be reported.
- Please wear a short sleeve shirt or blouse to allow accessibility for IV and BP cuff.
- A responsible person with a valid driver’s license MUST transport the patient to and from the appointment. This person must stay in the waiting area during the entire procedure.
- Any patient accepting any appointment for these procedures must specifically agree:
Not to drive a vehicle or operate any machinery the same day.
Not to undertake any responsible business matters. Avoid alcohol.
- If for any reason the appointment cannot be kept, please give sufficient advance notice for the time to be otherwise allotted.
- All intravenous solutions are irritating to some degree and although all precautions will be taken to minimize these effects, vein irritation following these procedures can occur. There may be material risks of: INFECTION, LOSS OF FUNCTION OR OF ANY LIMB OR ORGAN, PARALYSIS, PARAPLEGIA OR QUADRIPLEGIA, BRAIN DAMAGE, CARDIAC ARREST, OR DEATH.
I HAVE READ THE ABOVE INSTRUCTIONS AND CONSENT TO HAVING MY DENTAL
TREATMENT DONE WITH INTRAVENOUS CONSCIOUS SEDATION.
__________________________________ _____________________________________ __________________
Patient’s name Patient’s or guardian’s signature Date
Witness: __________________ Date: ________ Dentist: ________________ Date: _________ |
