Dental Anesthesia Consent Form
For Children
Intravenous Moderate Sedation, Deep Sedation/General Anesthesia Informed
Consent
Intravenous moderate sedation, also called conscious sedation, or intravenous deep
sedation are versatile modes of anesthesia available for dental office use today. They
provide the child with a tranquil, relaxed state, sometimes with or without loss of
consciousness. Some people experience amnesia, but amnesia is not a guarantee.
We require the child to be brought to our office one half hour prior to the
scheduled appointment with their dentist, to allow time for a pre-operative work-up, and
for any required oral medications that may need to be given to reduce the child’s fears
and anxiety.
After approximately one half hour, we will take the child, get them comfortably
positioned in our dental chair, and start them breathing nitrous oxide (laughing gas)/and
oxygen. Then, an intravenous catheter (IV) is inserted into a vein to administer the anesthetic
medications. The child’s vital signs are checked every three to five minutes. Emergency
equipment, supplies, and medications are immediately available at all times. A local
anesthetic is then administered, and sometimes nitrous oxide (laughing gas) and oxygen are
used along with the intravenous medications.
There are possible complications with any anesthesia, and I.V. moderate (conscious),
or intravenous deep sedation/general anesthesia are no exceptions. Although these are
relatively safe and acceptable modes of anesthesia, we cannot assure one that
complications will not occur. Possible common inherent risks are,
but not limited to drug reactions and side effects, nausea, recall of events, bruising, and vein
inflammation at the site of the intravenous injection.
After the child’s procedure they will be observed and receive care until they have
responded sufficiently to safely return home. Discharge from our office will be based on
them meeting a set of criteria. Since all people respond differently, it is difficult to say how
long the recovery stay will be, but stays ranging from thirty minutes to one hour
postoperatively are normal. Please be aware that if for some reason they do not meet our
discharge criteria, it is felt to be in their best interest that admission into a hospital may be
medically necessary.
After returning home they may be able to expect periods of wakefulness along with
sleepiness for the remainder of the day. Please read the before and after sedation
information below and then read and sign the consent form(s). Feel free to call us if
there are any questions.
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Before the Child’s Anesthetic
1. Important – Do not eat or drink for six hours prior to
the scheduled surgery.
2. Many times it is helpful have the child slightly sleep-deprived prior to their
appointment for the next day. Please discuss this option with the dentist the
anesthesia provider.
3. Notify the dentist immediately of any changes, even minor changes in physical
condition, such as a cold, nausea, bleeding, etc.
4. Dress warmly to the office if it is cold outside, but wear a casual loose fitting,
short-sleeved top.
5. Do not wear fingernail polish or heavy make-up, including mascara.
6. Bring a case to place any eyeglasses, contact lenses, or hearing aids in before
surgery.
7. Bring the child’s signed pre-anesthesia evaluations and all signed consent forms
with them.
8. The child may perform their usual bathing routine and brush their teeth.
9. After the child is treated, two adults are required: one to drive the vehicle, and
one to care for the child on the drive home.
10. A caregiver must be available and take care of the child for the next 24 hours
after the dental surgery.
11. Ask us any questions or concerns that one may have at any time prior to the
procedure.
After the Child’s Anesthetic
1. Discharge from the dental office will be based on the child’s street fitness, which
means they are not having any severe pain, they are not severely nauseated,
they can safely ambulate without assistance, their vital signs are stable and
within normal limits, and they respond appropriately to verbal stimuli.
2. For their safety, a responsible adult should care for the child and watch them
closely for the next 24 hours.
3. If sleeping, place them only on their side or stomach for at least the next six
hours after surgery.
4. Do not take any medications, especially depressant medications unknown or not
prescribed by the doctor without first consulting your doctor.
5. Do not allow the child to operate a bicycle, or anything requiring reflexes,
coordination, or balance, for at least 24 hours after the child’s anesthetic and
surgery as their responses could be dulled or slowed considerably.
6. Insist that the child rest and lay quietly for at least 24 hours.
7. Important decision-making, required by the child, should be delayed for at least
48 hours after their anesthetic and surgery.
8. Follow the doctor’s instructions and return to see him or her as directed.
9. If the child has any problems or there are any questions or problems regarding
the anesthetic and/or surgery, call the dental surgeon at
_____________________________ or Dr. ______________ at (___) ____-______.
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DO's and DON’Ts After Anesthesia
DON’T operate a bicycle or anything requiring reflexes, coordination, or
balance for at least 24 hours.
The child’s responses could be dulled or slowed considerably.
DON’T go up and down stairs unattended.
Try to stay on the first floor until recovered. Always hold on to someone’s arm as the
child may have balance problems due to the sedative medications.
DON’T allow the child to make any important decisions.
The potential for impairment relates not only to physical activities but to the
child’s mental state also. More over, the anxiety that frequently accompanies
important decisions is to be avoided. The day should be spent resting.
DON’T take any medications unless prescribed by or discussed with the
dentist or the dental anesthesia provider.
Some medications may adversely interact with anesthetic drugs or chemicals
remaining in the body. Included are prescription drugs, such as sleeping pills or
tranquilizers, and over-the-counter medications, such as aspirin.
DO allow the child to leave the health care facility accompanied by two
responsible adults.
These people will ensure that the child will travel home safely while someone
else drives, as well as provide immediate care at home. The child should
continue to have at least one responsible adult to provide care for 24 hours after
surgery.
DO remain quietly at home for the day and rest.
The child needs rest because they have received anesthesia, and because they
have undergone a surgical procedure, even one that is considered minor. If after
a day they still do not feel recovered, they may want to continue to rest for a day
or two. Discuss a planned return to activities with the dentist or dental
anesthesia provider.
DO take liquids first and slowly progress to a light meal.
Heavy foods can be difficult for the child’s system to digest, thereby increasing
the chance for discomfort. For their nourishment, start by taking liquids, and then
eat light foods, such as broth or soup, crackers or toast, plain rice, jello, milk
shakes, and yogurt. Remember not to use a straw.
DO drink a lot of water. Remember not to use a straw.
DO call the dental surgeon, the physician, or Dr. ___________________ if there
are any questions.
These professionals are interested in the child’s welfare and want their care to go
as planned. If there are any questions or problems, or feel recovery is not
progressing to satisfaction, call them at
___________________________________ or Dr. ______________ at ___)
____- _______. Available 24 hours, seven days a week.
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REMEMBER: Communication and cooperation are essential to the anesthesia
process. Active participation in the child’s care helps ensure their safety and
comfort.
CONSENT SECTION
The child and/or the parent(s)/legal guardian(s)
understand that the child must not consume foods for
6 hours before surgery.
The child and/or the parent(s), legal guardian(s) understand that the child
will be receiving I.V. moderate conscious sedation, or intravenous deep
sedation, along with local anesthetic, and possibly nitrous oxide and oxygen
gas.
The parent(s), or legal guardian(s) have not withheld any medical
information from the medical history forms regardless of its significance. The
child and/or the parent(s) have read the importance of their part in minimizing
any possible complications, and to help in determining the type(s) of
anesthesia the child will receive.
Prior to signing this form the child and/or the parent(s)/legal guardian(s)
have:
1. Read both BEFORE and AFTER sedation instructions and agree to
them.
2. Been told by my dentist or dental anesthesia provider not to consume
solids or liquids during the 6 hours before the child’s scheduled
anesthetic.
3. Been informed that there are certain risks and complications
associated with anesthesia, and that no guarantees have been made
to the child and the parent(s)/legal guardian(s), that none will occur.
4. Have made arrangements for at least two responsible adults to
accompany the child patient to the doctor’s office and to drive the child
patient home after surgery and be readily available should any child
patient’s needs arise 24 hours after surgery.
5. Been advised that in the first 24 hours after the anesthesia the child
patient should not operate a bicycle or anything requiring reflexes,
coordination, or balance.
6. Been advised that the child patient may believe their capabilities have
returned within a few hours after the anesthesia and surgery but that
this is not true and their mental faculties and physical skills could be
partially impaired at least 24 hours after the administration of any
anesthetic and other mediation that may be ordered or administered by
a dentist or dental anesthesia provider.
7. The child patient, the parent(s)/legal guardian(s) informed that on
occasion, the child patient may not feel completely recovered for 2 to 3
days
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Consent for Anesthesia Services
I,
(patient’s name)
, the child patient acknowledge that my
Dentist has explained to the child and the parent(s)/legal guardian(s), that the
child patient will have an operation, diagnostic, or treatment procedure(s). The
Dentist has explained the risks of the procedure(s), advised the child and the
parent(s)/legal guardian(s) of alternate treatments, and told the child and the
parent(s)/legal guardian(s) about the expected outcomes, and what could
happen if the child’s condition(s) remain untreated. The child and the
parent(s)/legal guardian(s) also understand that anesthesia services are needed
so that the Dentist can perform the operation or procedure.
It has been explained to the child and the parent(s)/legal guardian(s) that
all forms of anesthesia involve some risks and no guarantees or promises can
be made concerning the results of my procedure or treatment. Although rare,
unexpected severe complications with anesthesia can occur and include the
remote possibility of infection, bleeding, drug reactions, blood clots, loss of
sensation, loss of limb function, paralysis, stroke, brain damage, heart
attack, or death.
The child and the parent(s)/legal guardian(s)understand that these risks
apply to all forms of anesthesia and that additional or specific risks have been
identified below as they may apply to a specific type of anesthesia. The child and
the parent(s)/legal guardian(s)understand that the type of anesthesia service
listed below will be used for my procedure, and that the anesthetic technique to
be used is determined by many factors including the child’s physical condition,
the type of procedure(s) the child’s Dentist is to perform, his or her preference, as
well as the desire of the child and the parent(s)/legal guardian(s). It has been
explained to the child and the parent(s)/legal guardian(s) that sometimes an
anesthesia technique, which involves the use of local anesthetics, with or without
sedation, may not succeed completely, and therefore another technique may
have to be used including general anesthesia.
ORAL MINIMAL SEDATION
 Expected Result - Reduced anxiety and pain, partial, or total amnesia.
 Technique - Drug ingested into the stomach, breathed into the lungs, or by other
routes. producing a state of relaxation and relief of anxiety.
 Risks - An unconscious state, depressed breathing, injury to blood vessels, and
other risks.
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MONITORED ANESTHESIA CARE (MAC) Intravenous Sedation
 Expected Result - Reduced anxiety and pain, partial, or total amnesia.
 Technique - Drug injected into the bloodstream, breathed into the lungs, or
by other routes producing a semi-conscious state.
 Risks - An unconscious state, depressed breathing, injury to blood
vessels, and other risks.
DEEP SEDATION / GENERAL ANESTHESIA
 Expected Result – Partial or total amnesia, reduced pain and anxiety.
 Technique – Drug(s) injected into the bloodstream, or into a muscle, or
breathed into the lungs, or by other routes producing a deeply sedated
state.
 Risks – An unconscious state, depressed breathing, the necessity to
assist breathing, injury to muscles, injury to blood vessels, and other risks.
The child and the parent(s)/legal guardian(s) hereby consent to the
anesthesia service checked above and authorize that it be administered
by
, D.D.S. . The child and the parent(s)/legal guardian(s)
also consent to an alternative type of anesthesia, if necessary, as deemed
appropriate by him. The child and the parent(s)/legal guardian(s) expressly
desire the following considerations be observed (or write “none”):
none
.
The child and the parent(s)/legal guardian(s) certify and acknowledge that
they have read this form or had it read to me, that the child and the
parent(s)/legal guardian(s) understand the risks, benefits, alternatives and
expected results of the anesthesia service and that they had ample time to ask
questions and to consider their decision.
If there are any problems or there are any questions at any time please
feel free to call (___) ___-_____, available 24 hours a day, or the dental surgeon
of record at
.
The child and the parent(s)/legal guardian(s) have read the information and
they understand and agree with it. The child and the parent(s)/legal guardian(s)
give their consent for anesthesia to be provided by Allan Schwartz, D.D.S.
If at any time during the surgery the child becomes combative or we
cannot sedate the child comfortably and safely with the maximum allowable
medication, we will stop the surgery, and refer the child to the hospital for
treatment completion.
If the patient is not married and/or under the age of 18 years, a parent or
legal guardian must sign for them. Please state the relationship of the legal
guardian to the patient.
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(Time)
(Patient Name)
(Date)
(Time)
(Guardian Signature)/Relationship to Patient
(Date)
(Time)
(Witness Signature)
(Date)
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