, Consent for a Sedation


Medway Smile – Consent Form

    Medical History






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    INTRAVENOUS / ORAL SEDATION: AN INFORMATION SHEET FOR PATIENTS.

    You have probably been given this sheet because you are interested in having your dental surgery or treatment performed with the aid of oral / intravenous (IV) sedation.

    PLEASE READ THE REST OF THIS DOCUMENT AND ASK YOUR DENTAL SURGEON IF THERE IS ANYTHING THAT YOU DO NOT UNDERSTAND.
    What is IV sedation?

    IV sedation is a procedure that involves the injection of a drug called MIDAZOLAM into the blood. Midazolam has a number of effects, some of which vary from person to person. The main effect is that of relaxation, other short term effects include amnesia and tiredness.

    What is ORAL sedation?

    Oral sedation is given as a drink form half an hour before the appointment. We advise patients to bring with them a soft non-fizzy drink of their choice in which to mix the medicine with.
    Midazolam allows nervous or anxious patients to undergo treatment that they may otherwise have found too stressful. The technique is widely used in many medical specialities for all kinds of treatment and surgery.
    IV sedation is not the same as General Anaesthetic (GA). The IV sedated patient remains conscious throughout (although highly relaxed) and is able to speak with their Dental Surgeon during their treatment. (GA is nowadays only given in Hospitals and other suitably equipped centres). The main effect of IV sedation is for about 40 minutes; however the drug exerts an effect for at least another 12 hours. (this is why the instructions below must be followed).

    Why have IV sedation?

    Relaxes nervous or anxious patients. Avoids General Anaesthetic which is a more risky procedure. Can be performed by appropriately trained Dental Surgeons in practice. Allows nervous or phobic patients to undergo treatments from which they may otherwise have been excluded due to their anxiety.

    SPECIAL INSTRUCTIONS.
    1. Take all usual medication as normal.
    2. Do not eat or drink for 2 hours before the appointment.
    3. Bring a responsible adult to take you home by car.
    4. Do not drive or operate machinery for at least 24 hours after treatment.
    5. Do not make legal statements etc, for at least 24 hours after treatment.
    6. If you have young children make arrangements for a responsible adult to look after them for at least the night following your treatment.
    7. Do not drink alcohol for at least 24 hours after you treatment.
    8. Patients who have been given oral sedation become very drowsy, extra care is needed while waiting to be seen by the dentist. We will not be held responsible for any accidents or falls relating to the patient.

    CONSENT FOR DENTAL SURGERY UNDER IV SEDATION
    • I confirm that I have understood the documents titled 'Intravenous Sedation', an information sheet for patients.
    • I intend to follow the special instructions as described on the aforementioned sheet.
    • I have obtained any further information that I wish from the Dental Surgeon responsible for my treatment.
    • I am satisfied that my questions have been answered to my understanding and that I have received satisfactory explanations of the treatment and procedures the Dental Surgeon/Sedationist is to perform.
    • I confirm that I have read and agree with the above statements.


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