Skip to content
About Us
Expand
Dr. Amardeep Gill
Dr. Arman Sonuhi
Dr. Kirpaul Chattha
Our Services
Expand
Cosmetic Dentistry
Expand
Restorations
Expand
Gum & Bone Grafting
Periodontics
Dental Exams & Cleanings
Expand
Oral Cancer Exam
Pediatric Dentistry
Cleanings Prevention
Dental Anxiety And Fear
Dental X-Rays
Tooth Extractions
Expand
Wisdom Tooth Extraction
Dental Emergencies
Root Canal Therapy
Invisalign
Office Forms
Expand
New Patient Form
X-Ray Release Form
Contact Us
Book Now
Toggle Menu
Oral Sedation Consent Form
CONSENT TO CONSCIOUS ORAL SEDATION FOR RESTORATIVE AND ORAL SURGERY
Consent
(Required)
I understand that the purpose of conscious sedation is to more comfortably receive the necessary dental care. I understand that conscious sedation is not required to provide the necessary dental care. I understand that conscious sedation has limitations and risks, and absolute success of treatment cannot be guaranteed.
(Required)
Consent
(Required)
I understand that conscious sedation is a medically-induced state of awareness, but that conscious sedation does not produce a state of sleep. I understand that I will retain a decreased ability to respond during the procedure, and that my ability to respond normally returns when the effects of sedation wear off.
(Required)
Consent
(Required)
If, during the procedure, a change in treatment is required, I authorize the dentist and the operative team to make whatever change they deem in their professional judgement is necessary. I understand that I also have the right to designate an individual who will make such a decision on my behalf.
(Required)
I understand that there are risks and limitations to all dental procedures. For conscious sedation, these include:
Consent
(Required)
A. Inadequate sedation with initial dosage, which may require the patient to undergo the procedure without full sedation, or require delaying the procedure.
(Required)
Consent
(Required)
B. Atypical reaction to sedative drugs which may require emergency medical attention and/or hospitalization, including physical reaction, altered mental state, allergic reaction, illness or other condition.
(Required)
Consent
(Required)
C. Inability to discuss treatment options with the doctor while sedated, should circumstances require a change in treatment plan.
(Required)
My obligations for Conscious Oral Sedation:
Obligations
(Required)
I will need to have arrangements made for someone to drive me to and from my dental appointment. I will not be able to drive or operate machinery, or make important decisions such as signing documents, for 24 hours after my procedure.
Obligations
(Required)
I understand that I must notify the dentist if I am pregnant, have sensitivity to any medication, have recently consumed alcohol, or if I am presently on psychiatric mood-altering drugs or other medications. I must notify the dentist of any concerns with my present mental or physical condition.
Obligations
(Required)
I must have a completely empty stomach before undergoing the procedure.
IT IS VITAL THAT I HAVE NOTHING TO EAT OR DRINK FOR EIGHT (8) HOURS PRIOR TO ORAL SEDATION. Regularly taken medications can be taken with water only.
I have read and understood the risks and complications which may occur in connection with this procedure. I understand that the potential risks are not limited to those described above. I agree that I have been given and understood enough information to give my consent for the above procedure and to any other treatment or service deemed necessary or advisable. I have had the opportunity to ask questions and all such questions have been answered to my satisfaction. I have given a full and accurate report of my medical history, including allergies, conditions, medications and history of illness. I authorize and agree to undergo the procedure.
Today's Date
(Required)
DD slash MM slash YYYY
Name
(Required)
First Name
Last Name
Patient/Guardian Signature
(Required)
Treatment Provided by:
(Required)
Dr. Arman Sonuhi
Dr. Amardeep Gill
Dr. Kirpaul Chattha
Height
(Required)
Weight
(Required)
Dentistry Made Simple.
Thanks For Filling Out Our Form.
About Us
Toggle child menu
Expand
Dr. Amardeep Gill
Dr. Arman Sonuhi
Dr. Kirpaul Chattha
Our Services
Toggle child menu
Expand
Cosmetic Dentistry
Toggle child menu
Expand
Restorations
Toggle child menu
Expand
Gum & Bone Grafting
Periodontics
Dental Exams & Cleanings
Toggle child menu
Expand
Oral Cancer Exam
Pediatric Dentistry
Cleanings Prevention
Dental Anxiety And Fear
Dental X-Rays
Tooth Extractions
Toggle child menu
Expand
Wisdom Tooth Extraction
Dental Emergencies
Root Canal Therapy
Invisalign
Office Forms
Toggle child menu
Expand
New Patient Form
X-Ray Release Form
Contact Us
Book Your Appointment
Phone
