Oral Sedation Information and Consent Form

Please correct the errors described below.

This form is intended to document the discussion we have had regarding your planned conscious sedation procedure.

The medications we use are typically either Triazolam (Halcion), Lorazepam (Ativan), Diazepam (Valium) or Midazolam (Versed). These medications can greatly minimize anxiety that may be associated with going to the dentist. In a relaxed state, you will still be able to communicate with the dentist while treatment is being performed. Even though it is safe, effective and wears off rapidly after the dental visit, you should be aware of some important precautions and considerations.

Benefits of conscious sedation include reduced awareness of unpleasant sights, sounds and sensations associated with the procedure along with reduced anxiety. Most patients fall asleep, but not always.

I understand that it is critically important that I fully discuss my complete medical history with the dentist before sedative medications are administered especially any medications I’m taking.

You should not use these medications if you are PREGNANT, breast feeding, or have significant liver or kidney disease.

Tell the doctor if you are taking the following medications as they can adversely interact with the sedation medications: nefazodone (Serzone); cimetidine (Tagamet, Tagamet HB, Novocimetine or Peptol); levadopa (Dopar or Larodopa) for Parkinson’s disease; antihistamines (such as benadryl and travist); verapamil (Calan); diltiazem (Cardizem); erythromycin and the azole antimycotics (nizoral, biaxin, orporanox); HIV drugs indinavir and nelfinovir; and alcohol. Grapefruit juice should also be avoided. Taking recreational/illicit drugs can also cause untold reactions.

The dentist has reviewed the written instructions with me including expectations regarding food/drink intake, escort and activity after the sedation.

Sedation can be administered by multiple routes. Dr. Tapnio has discussed these options with me. I also understand that the sedation plan may need to be changed on the day of the procedure. I also acknowledge that no guarantee has been made as to the results that may be obtained.

During the discussion, I have had my questions answered to my satisfaction.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your message will be encrypted.