Oral Sedation Consent Form

The purpose of this informed consent form is to provide an opportunity for patients (and/or their parents/guardians) to understand and give permission for elective dental surgery. Each item needs to be agreed to after the patient (and/or parents/guardians) have the opportunity for discussions and questions.

First Name *

Last Name *

Date of Birth

I understand and agree to the planned treatment and consent to the administration of oral sedation for my procedure today. *

Agree

Disagree

I understand that the oral sedation will help me to relax during my procedure and I will still be able to respond to directions given to me. *

Agree

Disagree

I have been informed of possible side effects associated with having oral sedation. Such side effects include, but are not limited to: sedation, weakness, loss of orientation, headaches, change in appetite, sleep disturbances, dizziness, unsteadiness, amnesia, low blood pressure (hypotension). *

Agree

Disagree

I understand that I am unable to drive for 24 hours after having oral sedation. Therefore I need to arrange for a trusted adult to drop me off and pick me up from my appointment (please write their details below). I understand that I am not permitted to walk home or take a taxi/public transport. *

Agree

Disagree

First Contact Name *

Relationship *

Phone *

Second Contact Name *

Relationship *

Phone *

I accept the estimation of the fees as provided and agree to pay the final fee on the date of service or prior. *

Agree

Disagree

I certify that I speak, read and write English and have had my questions answered. I have read and fully understand this consent for oral sedation. *

Agree

Disagree