Patient Name

The purpose of this document is to provide an opportunity for patients to understand and give permission for moderate IV procedural sedation when provided along with dental treatment. Each item should be initialed after the patient has the opportunity to review.

1. I understand that the purpose Of sedation is to more comfortably receive necessary care. Moderate IV procedural sedation is not required to provide the necessary dental care. I understand that moderate IV procedural sedation has limitations and risks and absolute success cannot be guaranteed.
2. I understand that moderate IV procedural sedation is a drug-induced state of reduced awareness and decreased ability to respond. Moderate IV orocedurol sedcticn does not produce a state of sleep. I will be able to respond during the procedure. My ability to respond normally returns when the effects of the sedation wear off.
3. I understand that there are risks or limitations to all procedures. For sedation these include:
   1. Inadequate sedation with initial dosage which may require patient to undergo the procedure without full sedation or to have the procedure another time. An additional dose or doses may be required to complete the procedure.
   2. Atypical reaction to sedative drugs that may require emergency medical attention and/or hospitalization such as altered mental states. physical reactions. allergic reactions and other sicknesses. including respiratory or cardiac arrest.
   3. Inability to discuss treatment options with the doctor should circumstance requires a change in treatment plans.
4. If, during the procedure, a change in treatment is required, I authorize the doctor and the operative team to make whatever change they deem in their professional judgment is necessary. I understand that I have the right to designate the individual who will make such a decision.
5. I understand that I must notify the doctor if I am pregnant, or if I am lactating. I must notify the doctor if I have sensitivity to any medication. of my present mental and physical condition. if I have recently consumed alcohol, and if I am presently on psychiatric mood altering drugs or other medications.
6. I will not be able to drive or operate hazardous machinery for 24hours after my procedure. I understand I will need to have arrangements for someone to drive me to and from my dental appointment.