Sedation Consent | Jackson Pediatric Dentistry

Patient Information

Patient Name*

Weight

Height

Parent or Guardian

Parent or guardian name*

Phone*

Email*

Appointment date (if known)

Medications to be Used

Check each medication discussed with you. The dentist will recommend the right combination after reviewing your child's medical history and the planned treatment.

Versed (Midazolam)Liquid medication given by the dentist 30 minutes prior to the procedure. Most likely your child will not fall asleep and may still be fussy during the procedure. It will relax your child and decrease the memory of the visit, and help us perform the procedure safely.Atarax (Hydroxyzine)Antihistamine medication that is sometimes given at home or in the office to relax your child and reduce anxiety. The staff will instruct you regarding specifics with this medication and preferred pharmacy.Valium (Diazepam)Sedative intended to calm and reduce anxiety. This medication will be prescribed prior to your appointment and given at home one hour before the procedure.Nitrous Oxide / Oxygen (laughing gas)Sedation used for anxiety and pain control as well as to control gagging. This will help relax your child but not put them to sleep. There are minimal side effects, such as nausea. Three to ten minutes after the gas is discontinued, it will be out of your child's system.Local AnestheticWill be used in conjunction with the above medications.

Stabilization

To facilitate treatment safely, we may need to use stabilizers during the procedure. This would include the use of a papoose board with a Velcro blanket to wrap around your child. It may also be necessary to use a mouth prop to help hold the mouth open during treatment and at times have an assistant hold their hands.

I understand stabilization may be used to safely complete my child's treatment.*

Acknowledgment

I understand that to ensure a safe sedation procedure, I must be present in the office until treatment is complete. If during the procedure a change in treatment is required, I may be asked to make a decision in a timely manner.

I will remain in the office until treatment is complete and will be available for treatment-decision questions.*

Type your full name as electronic signature*

By typing your name above and submitting this form, you are providing an electronic signature on this consent.

Notes for our team (optional)

This form is for pre-procedure consent and reference. The signed paper consent will also be reviewed and signed with the dentist before sedation begins.