You have the right, as a patient, to be informed about the recommended anesthesia to be used during your dental procedure. Once you are informed of the risks, it allows you to make an educated decision on whether or not to receive the anesthesia. This disclosure is not meant to scare or alarm you; it is simply an effort to provide you with information so you may give or withhold your consent to receive anesthesia during your dental procedure.

Even when preformed correctly, anesthesia can be associated with risks. Although rare, unexpected complications with anesthesia can occur and include the remote possibility of the following: drug reactions, swelling, bruising, hematoma and/or phlebitis at the IV site, injury to blood vessels, aspiration, breathing and heart problems, nerve damage, cardiac arrest, brain damage or death.

Moderate IV conscious sedation is a drug-induced state of reduced awareness and a decreased ability to respond. You will be able to respond during the procedure, however, a certain degree of amnesia may occur. Conscious sedation is not general anesthesia (being put to sleep). You will maintain the ability to breathe on your own. Cardiovascular function is usually maintained. You are monitored closely and continuously throughout the procedure.

You will certify and acknowledge that you have read this form or had it read to you, that you understand the risks, benefits, alternatives, and the expected results of the anesthesia service. You understand that IV conscious sedation has limitations and risks, and absolute success cannot be guaranteed. You will further certify that you have had ample time to ask questions and to consider this decision.

You will sign in order to signify that all questions have been answered to your satisfaction regarding this consent and you fully understand the risks involved with the proposed anesthetic plan.

Your consent to Moderate IV conscious sedation in conjunction with your planned dental procedure is required in order for this treatment to be administered.