Steeles McLaughlin Family Dentistry

Oral Sedation Consent Form

18-545 Steeles Avenue West, Brampton, ON, L6Y 4E7      905-455-2023

Patient's Name:
E-mail Address

Oral Sedation (Anxiolysis) Pre-Operative Instructions:

  1. Take regular medications unless specified by Physician or Dentist.
  2. Do not eat or drink for 8 hours prior to the dental appointment.
  3. Patient must be driven to the office by a responsible companion.
  4. No smoking or drinking alcohol for 8 hours prior to the dental appointment.
  5. Sedative medications must be taken according to Dentist’s instructions.
  6. Patient must have NO chance of pregnancy (for Female patients)
  7. If you should develop a cold, flu, or other respiratory illness close to the time of your appointment, please call our office for possible rescheduling
  8. The patient should remove contact lenses prior to coming to the office

Oral Sedation (Anxiolysis) Post-Operative Instructions:

  1. Take all regular or prescribed medications as outlined by Physician or Dentist.
  2. No alcohol for 24 hours post-surgery.
  3. No driving for 18 hours post-surgery.
  4. Do not operate machinery for 18 hours post-surgery.
  5. Do not sign important documents nor make important decisions for 18 hrs.
  6. Must have a responsible companion escort patient home and observe recovery for at least 4 hours.

Patient Consent

Signature