Dr. Iván E. Rodriguez

Harlingen Office Address, 1610 East Harrison Ave,

suite A, Harlingen, Texas 78550

956-412-9500

Non- Intravenous Conscious Sedation Consent Form

Patient's Name
Phone
Email

I , request and authorize Dr. Iván E. Rodríguez, Adalí E. Vélez, Ernesto G. Treviño, and or Dr. Lisa Gortari ( Anesthesiologist ) to administer conscious sedation medications to me in conjunction with the Endodontic treatment.

Oral Sedation is provided to minimize anxiety and reduce restlessness during extensive dental procedures. It is safe, effective and its effect diminishes soon after the procedure has been completed. It is imperative however that the protocol described in this document be closely followed.

  1. Please read and ask any questions. Understand and sign this form and your surgical consent form prior to taking your pre-operative medication. You are unable to give informed consent while medicated and your procedure will not be performed without your valid, informed consent.
  2. The medication you have been prescribed is Halcion (Triazolam 0.25mg). It is a short acting drug in the Benzodiazepam class. This medication has mild sedative and muscle relaxing properties. Dosage instructions will be given by your doctor, written on the bottle and should be followed exactly.
  3. Because this medication is mildly sedating, it affects judgment and response time, and will make you sleepy. Therefore use of this medication in conjunction with dental treatment requires you to be escorted to and from your appointment. You should arrange a responsible escort and confirm with them well in advance of you appointment. Your escort must remain in the vicinity of the dental clinic for the duration of the appointment.
  4. Because the effect of this medication continues for an indeterminate period after treatment, driving or operating of any heavy equipment is prohibited for a period of 12 hours after administration of this medication.
  5. Oral Sedatives should not be ingested if you are pregnant, or breast-feeding. They should not be taken if you have kidney or liver disease, if you are hypersensitive to Benzodiazepines ( Valium, Ativan, Versed, ect ) or are taking any medication which adversely interact or amplify the effects of these medications (see medication reconciliation).
  6. Do not eat 6 hours prior to appointment. Clear liquids are allowed up to 2 hours before. After your procedure you will remain mildly sedated and should rest, preferably with a companion present, as you may be unsteady and could become disoriented.

My signature affirms that I understand these instructions and am willing to abide by the conditions described in this document. I have had the opportunity to ask questions, and have had them answered to my satisfaction.

Patient's Signature

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Parent/ Guardian Signature

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Doctor Signature

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