Consent to Operation

1. I hereby request and authorize Dr. David S. Cichon and his assistants to perform the following procedure (s): and any additional procedures indicated by an unforeseen condition arising in the course of the operation. I further request and authorize him/them to do whatever he/they deems advisable to treat the particular dental disorder/condition described to me as:

2. Even though local anaesthesia and sedation involves additional risks, for the protection from pain and discomfort during the operation, I consent to and request the administration of local anaesthesia (freezing) and Oral and or Intravenous sedation under the direction of Dr. Cichon to use such anaesthetics and/or sedative agents as he may deem advisable.

3. The nature and purpose of the operation, possible alternative methods of treatment, the risks involved, and the possibility of complications have been fully explained to me. I acknowledge that no guarantee or assurance has been made as to the results that may be obtained.

4. Just as there are risks and hazards in continuing my present dental condition uncorrected, there are also risks and hazards attendant to the performance of the surgical and/or diagnostic procedures planned for me. I realize that common side effects from sedation may include nausea, vomiting, drowsiness and fatigue. Though not a complete list, other less common hazards may occur which include: allergic reactions, minor discomfort, irritation to veins, blood clots, bruising of tissue and even death.

5. Medications, drugs, anaesthetics, and prescriptions may cause drowsiness, lack of awareness, and lack of coordination, any of which can be increased by the use of alcohol or other drugs. I have been advised not to undertake any hazardous activity or operate any vehicle, automobile, or hazardous device while taking medications and/or drugs, or until fully recovered from the effects of the same. I understand and agree not to operate any vehicle or hazardous device for at least 24 hours after my release from my dental appointment or until recovered from the effects of the anaesthetic medication and drugs that may have been given to me in the clinic for my care. I agree not to drive myself home after sedation and will have a responsible adult drive me or accompany me home after my discharge from the dental office.

6. I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT TO THE OPERATION AND THE EXPLANATION REFERRED TO OR MADE. I ALSO CERTIFY THAT ALL BLANKS OR STATEMENTS REQUIRING INSERTION OR COMPLETION WERE FILLED IN AND ANY INAPPLICABLE PARAGRAPHS WERE STRICKEN BEFORE I SIGNED. I ALSO STATE THAT I READ AND WRITE ENGLISH.

7. I FURTHER CERTIFY THAT I RECEIVED, READ AND UNDERSTAND THE PRE-OPERATIVE INTRAVENOUS SEDATION INSTRUCTIONS.

WITNESS:
DOCTOR:
DATE:
TIME:
SIGNED: