Nitrous Oxide Conscious Sedation Informed Consent

I hereby give my permission for the Doctors and staff at The Little Teeth Workshop to perform Nitrous Oxide sedation on my child. It is explained to my satisfaction the following and I understand that… Nitrous Oxide (laughing gas) is a safe method of sedation. It is only effective for mild to moderate levels of anxiety. It is well tolerated and has a rapid onset and reversible. There are potential side effects, potential hazards and risks that are infrequent, but none the less, may occur. They include, but are not limited to the following:

1-     Nausea and vomiting; this is the most common side effect of the Nitrous Oxide. The level of the Nitrous Oxide can be adjusted to eliminate this side effect.

2-     Drowsiness and ill coordination; this is a common side effect. My child should avoid for the remainder of the day any activities such as bike riding, swimming, using playground equipment, school, or any other activities where balance is important. My child should remain under responsible adult supervision for the remainder of the day.

3-     Behavioral Problems; some patients will talk excessively. It may be difficult to treat my child because he / she is so talkative, or experience vivid dreams associated with physical movement of the body.

4-     Shivering; it is not common but it may be uncomfortable. It usually develops at the end of the treatment when the Nitrous Oxide is terminated.

5-     Excessive Perspiration; sweating may occur during the procedure and my child may become somewhat flushed during administration of Nitrous Oxide.

6-     Expectoration; removal of secretions may be difficult but can be controlled by use of suction tip.

7– The child may become emotional or irritable after the sedation. It should be a short period of time, don’t be alarmed.

I have been advised of alternative treatment, and of the following.. The fear and anxiety of the dental experience and / or avoidance of future dental appointments, 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 that my child can expect from Nitrous Oxide sedation include.. Reduce anxiety, pain, and gagging, which make it easier for my child to cope with dental treatment. I hereby certify that I understand this authorization and the reasons for conscious Nitrous Oxide sedations and associated potential risks. I acknowledge that every effort will be made in my child’s behalf for a positive outcome from sedation, but no guarantees have been made to the result of the procedure authorized above.   I understand that there is a sedation fee of $99.00 due per each session. My dental insurance may not cover it. The responsibility is mine.