TREATMENT OF TEETH:

Nitrous Oxide Informed Consent

I hereby give permission for Dr. Karen Williamson and her staff to perform nitrous oxide sedation. Please make Dr. Williamson or any member of her staff aware if you could be or are currently pregnant.
I understand that the administration of medication and the performance of conscious sedation with nitrous oxide carry 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:
  1. The level of nitrous oxide will need to be adjusted if you begin to feel a sense of motion sickness or nausea. This is quickly made better by simply turning down the nitrous oxide and providing an oxygen flush. Please report any symptoms to Dr. Williamson or any member of her staff.
  2. Nausea and Vomiting: This is the most frequent for the side effects of nitrous oxide sedation but its frequency is still quite low. It is important to tell the doctor, hygienist, or assistant that you are experience some discomfort with your stomach. The level of nitrous oxide can be adjusted to eliminate this side effect.
  3. Behavioral Concerns: 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. It is okay to feel tingling in your hands and feet. Nitrous oxide does not put you to asleep, but may relax you enough that you fall asleep. If this happens, it is possible to have vivid dreams.
  4. 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.
  5. Excessive Perspiration: Sweating may occur during the procedure and you may become somewhat flushed during administration of nitrous oxide.
  6. Driving a Motor Vehicle: You may not feel capable of driving after nitrous oxide. If this occurs, we may keep you until you feel better or have you call a friend or family member to drive you home to insure your safety. You will not be able to call a cab or car service.
I have been advised of alternative treatment, the benefits and risks which include but are not limited to:
Fear, anxiety of dental experiences, 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, palpitations and other heart-related disorders.

The benefits one can expect from nitrous oxide sedation include: Help with anxiety and pain, gagging, high blood pressure due to anxiety, and medically compromised individual.
I hereby verify 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 out come from sedation, but no guarantees have been made to the result of the procedure authorized above.
  
Patient's Printed Name: Date:
Patient or Guardian Signature Date:  
Witness  Date:

Dr. Karen Williamson
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Date:
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