Download Oral Sedation Consent Form

KENNETH M. LUBRITZ, D.D.S., INC.
Periodontics and Dental Implants
2500 Fondren, Suite 330
Houston, TX 77063
Tel: (713) 789-7676
Fax: (713) 789-7051
THE ATTACHED FORMS MUST BE READ IN THEIR
ENTIRITY AND SIGNED BEFORE TAKING THE ORAL
SEDATION MEDICATION.
FORMS MUST BE BROUGHT TO APPOINTMENT SIGNED
IF FORMS ARE NOT SIGNED BEFORE ARRIVING TO
APPOINTMENT WE MAY HAVE TO RESCHEDULE YOUR
PROCEDURE.
KENNETH M. LUBRITZ, D.D.S., INC.
Periodontics and Dental Implants
2500 Fondren, Suite 330
Houston, TX 77063
ORAL SEDATION INFORMATION AND CONSENT FORM
TRIAZOLAM (Halcion)
Triazolam (Halcion), is a medication that 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.
1. This consent form and the dental treatment consent form should be signed before you take the
medication.
They are invalid if signed after you take the pills.
2. The onset of Triazolam is 15-30 minutes. DO NOT DRIVE after you have taken the medication.
For safety reasons and because people react differently, you should not drive or operate machinery
for the remainder of the day. Wait until tomorrow.
3. This medication should not be used if:
A. You are hypersensitive to benzodiazepines (Valium, Ativan, Versed, etc..)
B. You are pregnant or breast feeding
C. You have liver or kidney disease
Tell the doctor if you are taking the following medications as they can adversely interact with Triazolom:
Nefazodone (Serzone), Cimetidene (Tagament, Tagament HB, Novocimetine, or Peptol), Levodopa (Dopar or
Larodopa) for Parkinson’s disease, antihistamines (such as Benadryl and Tavist), Verpamil (Calan), Diltiazem
(Cardizem), Erythromycin and the Azole Antimycotics (Nizoral, Biaxin or Sporanox), HIV drugs such as
Indinavir and Nelfinovir and Alcohol. Of course, taking recreational drugs/illicit drugs can also cause untoward
reactions.
4. Side effects may include light-headedness, headache, dizziness, visual disturbances, amnesia, and
nausea in some people, oral Triazolam may not work as desired.
5. Smokers will probably notice a decrease in achieved medicinal results.
6. You should not eat heavily prior to your appointment. You may take the medications with a small
amount of food; such as juice, toast, etc.., taking it with too much food can make absorption into
your system unpredictable.
7. Nitrous Oxide (laughing gas) may be used in conjunction with Triazolam and a local anesthetic.
8. On the way home from the dentist, your seat in the car should be in the reclined position. When at
home lie down with your head slightly elevated. Someone should stay with you for the next several
hours because of possible disorientation and possible injury from falling.
I understand these considerations and am willing to abide by the conditions stated above. I have had an
opportunity to ask questions and have them answered to my satisfaction.
Signed (patient):_______________________
Date:_______________
Signed(guardian, if patient is under the age of 18):_______________________________________________
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KENNETH M. LUBRITZ, D.D.S., INC.
Periodontics and Dental Implants
2500 Fondren, Suite 330
Houston, TX 77063
CONSENT FOR SEDATION
I, ____________________________________, give consent for ___________________________________ to receive dental
treatment under sedation and do authorize Dr. _____________________________ to provide the following services:
I understand that the treatment plan may need to be altered during treatment. I authorize Dr. ___________________________ to
provide any necessary alternative or additional treatment.
The nature of the dental treatment, the risks and alternatives have been fully explained to me including the risk and alternatives of
refusing dental treatment.
All patients undergoing sedation are subject to the risk of medical complications including, but not limited to: sore throat, discomfort,
bleeding, swelling, nausea and vomiting, allergic reactions, respiratory and cardiovascular problems and death.
I understand that the explanation of the risks and consequences that I have received is not exhaustive and that other less common risks
may arise. I have been advised that these less common risks will be explained to me upon request.
I understand that the sedative medication may not make me (my child, if minor) “fall asleep” and that I (my child) may be awake
during treatment.
Through my signature, I acknowledge that I have read this document in its entirety and that I fully understand it. I have been given
the opportunity to discuss this information and have had all of my questions answered. I request and consent to the above treatment
for myself (child if minor).
___________________________________________
Patient/Parent/ Guardian’s Signature
____________________________
Date
___________________________________________
Printed Name
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KENNETH M. LUBRITZ, D.D.S., INC.
Periodontics and Dental Implants
2500 Fondren, Suite 330
Houston, TX 77063
Sedation/Anesthesia Plan
Although I understand that sedation/anesthesia involves additional risks and hazards, I request and hereby consent to the use of
sedative/anesthetic agents for the relief of potential pain or anxiety during the planned procedures. After explanation and discussion
with the doctor, I agree to the following anesthesia plan (check one):
( ) local anesthesia only
( ) oral conscious sedation
( ) inhalation conscious sedation (nitrous oxide/oxygen gas)
( ) intravenous conscious sedation
( ) deep sedation/nonintubated general anesthesia
( ) intubated general anesthesia
Furthermore, I understand that if any anesthesia plan I have agreed to does not adequately alleviate my pain and anxiety levels, the
anesthesia plan may be changed. I also understand that certain potential complications may result from the use of any anesthetic agent
and may included respiratory depression, drug reaction, paralysis, cardiac arrest, brain damage or even death. Other
recognized risks that may result from the general anesthesia range from minor discomfort to injury to vocal cords, eyes or teeth.
Anesthesia Precautions
Medications, anesthetic agents and prescription drugs may cause drowsiness and a lack of awareness and coordination which can be
increased by the use of alcohol or other drugs. I have been advised not to operate any vehicle, automobile or hazardous devices or
machinery while taking such medications and/or drugs until fully recovered from the effects of the drugs. I understand and agree not
to operate any vehicle, hazardous device or machinery for at least twenty-four (24) hours after my release from surgery or until fully
recovered from the effects of the anesthetic medications or drugs given to me for my dental treatment. I agree not to drive myself
home after surgery and, if applicable, will have a responsible adult drive me or accompany me to the clinic and home after my
discharge from surgery.
I agree and understand I am not to have and have not had anything to eat or drink for ___hours before my surgery.
I acknowledge and state that I have made a full disclosure of my current and past medical and health history, including all drugs,
medications, hospitalizations, surgeries and past or present substance abuse.
Furthermore, I understand that because successful treatment may depend on compliance with the doctor’s instructions, I agree to
cooperate completely with the instructions of the doctor and/or his/her assistant while I am under his/her care, realizing that any
failure to comply with instructions may result I a less than optimum result.
I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND
WORDS WITHIN THE ABOVE CONSENT TO THE OPERATION, ANESTHESIA PLAN AND THE EXPLANATION
REFERRED TO OR MADE AND THAT ALL BLANKS OR STATEMENTS REQUIRING INSERTION OR
COMPLETION WERE FILLED IN AND INAPPLICABLE PARAGRAPHS, IF ANY, WERE STRICKEN BEFORE I
SIGNED.
_____________________________________
Patient, Parent or Guardian
_______________________________
Witness
____________________________________
Doctor
________________________
Date
______________
Date
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KENNETH M. LUBRITZ, D.D.S., INC.
Periodontics and Dental Implants
2500 Fondren, Suite 330
Houston, TX 77063
Instructions for Patients Prior to Oral Conscious Sedation
Eating and Drinking
It is extremely important that patients have an empty stomach prior to anesthesia. For this reason, adults and teenagers are not to have
anything to eat or drink for six (6) hours before their scheduled appointment. If you have morning appointment, do not eat or drink
anything after midnight.
Change in Health
Prescription medications should be taken as scheduled with a sip of water unless otherwise noted by this office. Please inform this
office of all the medications you are currently taking and have taken within the last two (2) weeks.
Clothing
On the day of the surgery, it is suggested that you wear loose fitting clothing and comfortable shoes. Please remove nail polish if
possible. Contact lenses must be removed prior to anesthesia. Leave all valuables at home.
Designated Driver
A responsible adult must accompany any patient to the office and remain there during the procedure. Do not take a taxi or bus.
Arrange to have a responsible adult spend at least four (4) hours with you at home after your anesthetic.
Please contact this office if you have any questions.
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