Nitrous Oxide Sedation Consent Form

First Name*

Last Name*

Date of Birth

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I consent to the use of nitrous oxide sedation. * I consent to the use of nitrous oxide sedation. * Agree Disagree

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

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

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 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 * Agree Disagree

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 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. * Agree Disagree

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

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