Oral Sedation Take Home Information and Consent

ORAL SEDATION TAKE HOME INFORMATION AND CONSENT

Triazolam (.25mg) or Lorazepam (1mg sub lingual tablets) are usually administered in our office 60-90 minutes prior to your dental appointment. This creates a safe and calming environment for you and your dentist. In a relaxed state, you will still be able to communicate while treatment is being performed. Even though it is generally safe and effective, you should be aware of some important precautions and considerations.

  • You must come in 90min prior to your appointment and be given the pills in our office. If your appointment is in the morning, DO NOT eat breakfast. If it is later in the day, DO NOT eat 6 HOURS prior to your appointment. You may have clear fluids 2hours prior to your appointment.
  • Do not smoke or use alcohol, antihistamines or street drugs for at least 24hours before your appointment. Smokers may notice a decrease in the effectiveness of the drug. Do not drink grapefruit juice, caffeine or take St. John's Wort or antifungal medications for 48 hours prior to your appointment. Take other medications regularly on time.
  • Please make arrangements for a responsible adult to pick you up after your appointment and STAY WITH YOU for the rest of the day (at least 4hours). You are not to be left unsupervised. In rare cases, 're-sedation' can occur out of the office (often after eating) before sedative wears off (around 8 hours). After your appointment, you should not drive or operate machinery, consume alcohol, or make important decisions for 18 hours. Do not return to work or school the day of your visit. You will not be permitted to leave until the designated adult arrives so assure they can come promptly.
  • The peak effect of the drug is usually reached in 1-2 hours, and you should feel mostly back to normal in 6-8 hours. Side effects may include lightheadedness, headache, dizziness, visual disturbances, amnesia, nausea, or allergic reactions. There is an extremely rare chance of more serious conditions necessitating hospitalization, such as respiratory depression and cardiac arrest. For this reason, we will review your medical history-please be as accurate as possible in your responses.
  • The degree of sedation depends on the individual's biochemistry and metabolism and thus is hard to predict. For your safety, we start you at a lower dose. Therefore, occasionally the sedation effect is not strong enough to permit dental work to be done comfortably. Depending on our schedule, we may offer you additional medication and/or Nitrous Oxide, or we may need to reschedule your appointment and try again at a higher dosage on another date.
  • Occasionally, unforeseen circumstances may arise during treatment, and a different treatment plan needs to be executed. In the rare case this occurs, we will do our best to communicate the change in plan to you and get your input. In the event that you are unable to comprehend the adjusted treatment, you agree to allow Dr. Cichon or Dr. Reddick to use their professional discretion in determining how to proceed. We will NOT perform major treatment changes or unexpected extractions without your full informed consent, and in these cases, we may need to reschedule your appointment to ensure you have full capacity.
  • Your medical history and vital signs will be updated and you will be asked to sign this consent form for our records and for yours.
  • If you go to the hospital or seek the care of a doctor for any reason within 10days of the procedure, you must inform our office. This is a requirement of the Alberta Dental Association and College.

I authorize the dentist to use his best judgment in managing unforeseen conditions, which might unexpectedly arise during the course of oral sedation and the planned dental procedures.

I acknowledge that lack of cooperation with recommendations made concerning dosage and other protocols associated with oral sedation may contribute to less than desired results.

I understand these considerations and am willing to abide by the conditions stated above. I have had an opportunity to ask questions and have had them answered to my satisfaction.

Print Name:
Date:
Designated Adult's name:
DDS: