9 Holly Hill Drive
Petersburg, Virginia 23805-2559

(804) 733-9490

FAX (804) 733-3564

10320 Memory Lane, Suite A
Chesterfield, Virginia 23832

(804) 748-9553

FAX (804) 748-0460

Conscious/moderate Sedation Informed Consent Form

The purpose of this document is to provide an opportunity for patients to understand and give permission for conscious/moderate sedation (oral and/or intravenous) when provided along with dental treatment. Carefully review each of the following items and please ask your doctor any questions you may have.

  1. I understand that the purpose of conscious/moderate sedation is to more comfortably receive necessary dental care. Conscious/moderate sedation is not required to provide the necessary dental care, and the alternative is to have my procedure performed under local anesthesia only.
  2. I understand that conscious/moderate sedation is a drug induced state of reduced awareness and decreased ability to respond. Conscious/moderate sedation is not general anesthesia (being put to sleep). My ability to breathe on my own and respond to verbal commands will remain throughout my dental care under conscious/moderate sedation.
  3. I understand that conscious/moderate sedation has limitations and risks, and absolute success cannot be guaranteed. For conscious/moderate sedation these include:
    1. Inadequate sedation requiring undergoing the procedure without adequate sedation, or delay the procedure to another day.
    2. Atypical reaction to sedative medications which may require emergency medical attention and/or hospitalization for conditions such as: altered mental status, physical reactions, allergic reactions and other sicknesses.
  4. If, during the procedure, a change in treatment is required, I authorize my doctor to make whatever change he deems necessary in his professional judgment.
  5. I agree to the type of anesthesia, depending on the choice made by the doctor. I agree not to operate a motor vehicle or hazardous device, and not make any important decisions for at least 24 hours or more until fully recovered from the effects of the anesthesia or drugs given for my care.
  6. To my knowledge, I have given an accurate report of my physical and mental health history including current/possible pregnancy, lactation, and current medications/supplements. I have also reported any prior allergic or unusual reactions to drugs, foods, insect bites, anesthetics, pollens, dust, blood or body diseases, gum or skin reactions, abnormal bleeding, obstructive sleep apnea or any other conditions related to my health. I will notify my doctor if any changes occur to my medical history.
  7. I do not have a history of hypersensitivity to benzodiazepines (Halcion (Triazolam), Valium (Diazepam), Ativan (Lorazepam), Versed (Midazolam), etc.), nor do I have liver and kidney dysfunctions.
  8. I will arrange for a responsible person (adult) to drive me to and from, and wait for me during my procedure under conscious/moderate sedation.
  9. I will not eat or drink (except small amount of water when taking medications) for at least 6 hours prior to my conscious/moderate sedation procedure. I agree to wear loose, comfortable clothing. Not wear contact lenses. Not to have fingernails painted.

I hereby consent to conscious/moderate sedation in conjunction with my planned dental procedure.


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