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Nitrous Oxide Sedation Consent Form


Nitrous Oxide is a colourless, slightly sweet gas that is used during dental treatment for relaxation, pain and anxiety relief. When inhaled, it can induce feelings of euphoria and sedation. It can also produce sensations of drowsiness, warmth and tingling in the hands, feet and/or about the mouth. In the dental setting, it will not induce unconsciousness. You will be able to swallow, talk and cough as needed.

Nitrous Oxide sedation should not be used during pregnancy.

Pre-operative guidelines

Nitrous oxide is administered through a nasal mask. You must be able to breathe through the nose (blocked nasal passages, colds etc, will defect the idea of using nitrous oxide for relaxation). Avoid caffeinated products before coming in for treatment. Nitrous oxide may cause “stomach butterflies” (nausea), which may result in vomiting. Please inform the Dentist of your current medications.

Instructions during nitrous oxide use

Your mask must remain firmly in place during the entire period. Do not breathe through your mouth. Breathe through the nose only. Notify the doctor if you are experiencing difficulty breathing through your nose. You cannot talk while nitrous oxide is being used. Talking blows nitrous oxide into the room air, lessening the desired effect for you and exposing the dental staff to nitrous effects.

Post-operative guidelines

Recovery from nitrous oxide sedation is rapid. The gas will be flushed from your system with oxygen. If you feel dizzy after the sedation, remain seated. The sensation usually passes in a few minutes. Do not leave the office until your head feels clear and you are able to function (i.e. walk and drive) safely.

Nitrous Oxide Sedation Consent Form

I consent to the use of nitrous oxide sedation. *

The reasons and benefits of having nitrous oxide sedation has been explained to me. *

I have been informed of possible risks and complications which include, but are not limited to: Nausea, Dizziness, Drowsiness, Feeling of claustrophobia *

I understand the importance of my medical history and affirm that I have informed my Dentist of my medical conditions and current medications. I understand that failure to give true health information may adversely affect my care and lead to unwanted complications. I have informed my Dentist if I suffer from any of the following: Congestive heart failure, Chronic Obtrusive Pulmonary Disease (COPD), Chronic Bronchitis, Emphysema, Chronic asthma, Bronchiectasis, Pregnancy, Hepatitis B or C, Tuberculosis, Macrocytic anaemia, Immune diseases, Respiratory diseases, Middle ear infections, Claustrophobia, History of substance abuse *

I realise that, despite all precautions that may be taken to avoid complications, there can be no guarantee as to the effect of the sedation will have on me. *

I accept the estimation of the fees as provided and agree to pay the final fee on the date of service or prior. *

I certify that I speak, read and write English and have had my questions answered. I have read and fully understand this consent form. *

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