Downtown Whitby Dentistry

Anasthesia Consent Form

130 Byron Street North, Whitby, ON, L1N 4M9      905-430-7045

Patient's Name:
E-mail Address

Consent for Anasthesia

Discomfort, swelling, numbness and irritation of the vein (thrombophlebitis) that may result from intravenous and/or intramuscular injections.

I understand I will routinely be given local anesthesia (unless allergic) but may also choose supplements such as nitrous oxide, oral premedication, intramuscular and/or intravenous anesthesia (conscious sedation that may be deepened according to a patient’s needs) my decision is based on my discussion with and the judgement of the dentist involved in my case.

Medication, drugs, anesthetic and prescriptions cause drowsiness and lack of awareness/coordination, which is increased with alcohol and or other drugs. I have , therefore been advised not to drink or take drugs other than my prescription medications: not to operate any vehicle or hazardous device: not to work or make important decisions while taking any medications and or until fully recovered from anesthetic medication given to me for oral surgery. I agree to have a responsible adult drive me home after the dental procedure and stay with me until fully recovered from anesthetic effects.

Most procedures are routine and serious complications are not expected. Those, which do occur, are most often minor and can be treated.

Treatments

Proposed Treatment:

Patient Consent

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