Reason for recommending oral sedation:

Oral sedation would be recommended to patients who are nervous about treatment, who may experience anxiety, by having complex surgery or a long extended appointment. Thus the oral sedation will help to make you feel relaxed, calm and sleepy for your treatment.

Medication and administration:

The medication we use is called Lorazepam. The dosage is tailored to the patient’s needs by the treating dentist. The Dentist will crush the required number of tablets into a powder that will be administered orally and placed under the tongue to dissolve. The time it takes to feel the effects is different for each patient; generally within the hour. We expect the effects of the oral sedation to last in your system for 24 hours. You are not permitted to drive for 24 hours following the administration of oral sedation medication.

About your appointment:

You must be dropped off and collected by a friend or family member.

You will be required to arrive an hour prior to your appointment. When you arrive, we will process the payment for your treatment and have you sign consent forms before the Dentist administers your oral sedation. This is required due to the side effects you will feel while on the medication. You will then be taken to our recovery room where you can relax in privacy and comfort. Once the Dentist has administered the oral sedation, our friendly front office team will check in on you every 15 minutes until you are taken through for your appointment.

When your appointment is completed, we will call your contact person to collect you. You are not permitted to walk home or take a taxi/public transport. As the effects of the medication will still be in your system, it is recommended you have a trusted adult to supervise for 2 – 3 hours following.

Your Consent

The purpose of this informed consent form is to provide an opportunity for patients (and/or their parents/guardians) to understand and give permission for elective dental surgery. Each item needs to be agreed to after the patient (and/or parents/guardians) have the opportunity for discussions and questions.
First Name
Last Name
Date of Birth
I understand and agree to the planned treatment and consent to the administration of oral sedation for my procedure today. *
Agree
Disagree
I understand that the oral sedation will help me to relax during my procedure and I will still be able to respond to directions given to me. *
Agree
Disagree
I have been informed of possible side effects associated with having oral sedation. Such side effects include, but are not limited to: sedation, weakness, loss of orientation, headaches, change in appetite, sleep disturbances, dizziness, unsteadiness, amnesia, low blood pressure (hypotension). *
Agree
Disagree
I understand that I am unable to drive for 24 hours after having oral sedation. Therefore I need to arrange for a trusted adult to drop me off and pick me up from my appointment (please write their details below). I understand that I am not permitted to walk home or take a taxi/public transport. *
Agree
Disagree
First Contact Name
Relationship
Phone
Second Contact Name
Relationship
Phone
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 for oral sedation. *
Agree
Disagree

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