Download Sedation Consent

CONSENT FOR THE USE OF
SEDATION FOR PEDIATRIC DENTAL TREATMENT
AND ACKNOWLEDGEMENT OF RECIEPT OF INFORMATION
State law requires us to obtain your consent to your child’s contemplated treatment. Please read this form carefully and ask about
anything that you do not understand. I, ________________________________, as the legally responsible parent/guardian of
____________________________ give my consent to the use of local anesthetics and sedative drugs Dr. Burkitt may deem necessary
or advisable so as to enable them to render necessary dental treatment as indicated on the child’s examination chart, as previously
explained to me, and any other procedure deemed necessary or advisable as a corollary to the planned treatment, with the exception of:
________________________________________ (if none, so state).
I understand that state law also requires health professionals to provide their prospective patients with information regarding the
treatment they are considering. I acknowledge receipt of the instructions to parents of pediatric patients who are to receive sedation for
dental treatment.
I understand that occasionally there are complications of the treatment, drugs, or anesthetic agents, including but not limited to:
numbness, infection, swelling, bleeding, discoloration, nausea, quadriplegia, paraplegia, the loss or loss of function or any organ or limb,
or disfiguring scars associated with such procedures. I further understand and accept that complications may require hospitalization and
may even result in death.
The complications of this procedure have been discussed with me to my satisfaction. I acknowledge the receipt of and understand the
preoperative and postoperative instructions. The treatment and sedation procedures have been explained to me, to my satisfaction, along
with possible alternative methods and their advantages and disadvantages, risks, consequences and probable effectiveness of each as
well as the prognosis if no treatment is provided. I am advised that though good results are expected, the possibility and nature of
complications cannot be accurately anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the
result of the treatment or as to cure.
I hereby state that I have read and understand this consent and that all questions about the procedure or procedures have been
answered in a satisfactory manner.
PARENTS INSTRUCTIONS FOR OUR PATIENT’S
SAFE AND SUCCESSFUL SEDATION
Occasionally, children need to be sedated to allow for the successful completion of dental care. This is a decision we must make
together; both parents and the dentist need to be clear in the reasons behind the need for sedation. Once the decision is made to use a
sedative drug, certain rules must be followed to decrease risk to the child. We ask you to read and follow these guidelines:
Definition: Conscious Sedation is a minimally depressed level of consciousness that retains independently and continuously an airway
and responds appropriately to physical and /or verbal command.
Because of the inherent risks of medical/dental procedures of this nature, your informed consent is required. Please read and if
completely understood and satisfied, sign the informed consent form. Dr. Burkitt is more than happy to answer or explain any questions
you may have.
I have read and understand the preceding information and it has been explained to me to my satisfaction, including all pre and
post operative instructions.
Patient’s Name: __________________________________________ Date: __________________________ Time:_______________
Signature of Parent or Guardian: ________________________________________ Relationship to child:
_______________________
I certify that I explained the above procedures to the parent/guardian before requesting their signature.
Signature of Dentist: __________________________________________________________________________________________
OFFICE USE
Any changes in child’s health since last visit? Y_____ N _____ Initial ______ If yes, explain: _____________________________
Food/Drink last 6 hours? Y_____ N _____ Initial _____ If yes, explain: _______________________________________________
Age: ___________
Weight: ______________
B.P. ________
Pulse________ @ ________
O2%________
BP ________
Pulse ________ @ ________
O2% ________
BP ________
Pulse ________ @ ________
O2% ________
Demerol/Diphenhydramine/Hyrdoxyzine oral ______/______/______@_______
End Time: _________
BP ________
Pulse ________ @ ________
O2% ________
Instruction’s for your child’s sedation
Conscious sedation is utilized to reduce excessive anxiety or to calm an active child to a level that quality dental
treatment can be accomplished. Conscious sedation is not intended to put your child fully to sleep, nor does it
work for every child.
A specific dosage of a mixture or oral drugs Demerol, Diphenhydramine and Hydroxyzine are given according
to the child’s weight the date of appointment.
For best results please:
1. It is necessary for the child to have nothing to eat or drink 6 hours prior to the appointment.
This includes water the morning of the treatment. Breaking this requirement will mean cancellation of
your child’s appointment.
2. Please dress your child in loose fitting, comfortable clothing. We recommend pajamas.
3. Please notify us of any changes in your child’s health or medical condition. Call us with as much
notice as possible at 918-250-5030 if the child has an illness more severe than a slight runny nose.
4. You must tell the doctor of any drugs that your child is currently taking (prescribed, over-the-counter,
or herbal medications) and any drug reactions, and/or changes in medical history.
5. Please have the child visit the restroom before receiving dental treatment.
6. Make plans to be in the office for two to three hours during the sedation appointment. A parent or
guardian MUST remain in the office so that any questions may be addressed immediately.
7. Please watch your child closely while the medication is taking effect. Hold the child in your lep and
keep close to you. Do not let them “run around”
8. After the dental treatment is complete he/she may require more attention than usual. Because of this,
it is advisable that you find alternate care for any other children in the family, especially younger
family members. Expect your child to be sleepy, irritable, or nauseous for the next few hours. Be
prepared to have your child watched closely for the rest of the day. Do not plan any other activities for
the same day. Your child will not be allowed to return to school or day care on the day of the sedation
appointment, but should be ready to go back the following day.
9. Please securely restrain child in seat belt/car seat with adult supervision on your car ride home. An
adult needs to watch the child to keep head propped up and airway open. Once you get home, if they
child wants to sleep place them on their side with their chin up.
10. The child will experience numbness of the cheeks, lips or tongue from the local anesthetic given for
dental treatment. This may last up to two hours following his/her appointment. Please watch your child
closely to minimize the chance of them biting on their lip, tongue or cheeks.
If you have any further questions regarding the sedation or appointment times,
please call our office at 918-250-5030