NITROUS OXIDE CONSENT


I hereby give permission for Dr. and staff to perform nitrous oxide sedation.

If my insurance rejects this procedure I understand I am responsible to pay the remaining balance.

I understand that the administration of medication and the performance of conscious sedation with nitrous oxide carries certain common hazards, risks, and potential unpleasant side effects which are infrequent, but none the less, may occur. They include but are not limited to the following:

  • Excessive Perspiration: Sweating may occur during the procedure and you may become somewhat flushed during administration of nitrous oxide.
  • Expectoration: Removal of secretions may be difficult but can be controlled by use of suction tip.
  • Behavioural Problems: Some patients will talk excessively. You may become difficult to treat because you are so talkative, or experience vivid dreams associated with physical movement of the body.
  • Shivering: Although not common, shivering can be quite uncomfortable. Shivering usually develops at the end of the sedative procedure when the nitrous oxide has been terminated.
  • Nausea and Vomiting: This is the most frequent of the side effects of nitrous oxide sedation but it's frequency is still quite low. It is important to tell the doctor, hygienist, or assistant that you are experiencing some discomfort. The level of nitrous exude can be adjusted to eliminate this side effect.
  • Driving a Motor Vehicle: You may not feel capable of driving after nitrous oxide. If this occurs, we will keep you until you feel better or have you call a friend or cab to insure your safety.

I have been advised of alternative treatment, the benefits and risks which include but are not limited to: Fear and anxiety of the dental experience and/or avoidance of future dental appointments. These fears and anxiety, if not diminished by the use of nitrous oxide sedation, may precipitate other medical problems including fainting, palpitation and other heart-related disorders.

The benefits one can expect from nitrous oxide sedation include: Help with anxiety and pain, gagging and medically compromised individual.


I hereby certify that I understand this authorization and the reasons for the above-named sedative procedure and associated risks. I am aware that the practice of dentistry is not an exact science. I acknowledge that every effort will be made on my behalf for a positive outcome from sedation, but no guarantees have been made to the result of the procedure authorized above.

I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT AND THE EXPLANATIONS/LIMITATIONS PROVIDED. I ALSO STATE THAT I READ AND WRITE IN ENGLISH; IF THIS IS NOT THE CASE I CERTIFY THAT I HAVE HAD THE OPPORTUNITY TO HAVE THIS DOCUMENT TRANSLATED FOR ME.