DENTAL TREATMENT CONSENT
The doctor has explained to me that, during the course of the procedure(s) unforeseen conditions may be revealed that
necessitate an extension of the original procedure(s) or different procedure(s) than those set forth in above. I therefore authorize
and request the persons described in paragraph 1 above to perform such procedures as are necessary and desirable in the
exercise of professional judgment. The authority granted under this paragraph shall extend to the treatment of all conditions
that require treatment and are not known at the time of the original procedure is commenced.
I consent to the administration of anesthesia, including local anesthesia, deep sedation, conscious sedation, nitrous
oxide/oxygen analgesia, intravenous, and/or general anesthesia in connection with the procedure(s) referred to above, by any
of the persons described above, and to the use of such anesthetics as may be deemed advisable with the exception of:
to which I said I was allergic.
(none or name of particular
anesthetic)
Medications, drugs, anesthetics and prescriptions may cause drowsiness, lack of awareness and coordination, and nausea,
which can be increased by the use of alcohol or other drugs; thus, I have been advised not to operate any vehicle, automobile or
hazardous devices, or work, while taking such medications and/or drugs; or until fully recovered from the effects of same. I
understand and agree not to operate any vehicle or hazardous device for at least twenty-four (24) hours after my release from
surgery or until further recovered from the effects of the anesthetic medication and drugs that may have been given to me in the
office or hospital for my care. I agree not to drive myself home after surgery and will have a responsible adult drive me or
accompany me home after my discharge from surgery.
It has been explained to me and I understand that a perfect result is not guaranteed or warranted and cannot be
guaranteed or warranted.
I understand that I may not have anything to eat or drink for eight (8) hours before surgery under IV sedation/general
anesthesia (unless otherwise instructed).
I have had ample opportunity to seek other opinions attendant to my care.
1 certify that I read and write English and have read and fully understand this consent for treatment. PLEASE ASK THE
DOCTOR IF YOU HAVE ANY QUESTIONS CONCERNING THIS CONSENT FORM.
Do not sign this form unless you have read it, understand it, and agree with what it says.
Patient's Signature Date
Parent or Legal Guardian (If under 18) Date
Witness (Professional staff member) Date
I attest that I have discussed the risks, benefits, consequences and alternatives of the procedure with _______________
___________________(Patient or Patient’s Representative) who has had the opportunity to ask questions, and I believe
understands what has been explained.
20
Dentist's Signature Date
Witness (Professional staff member) Date
JA NUA RY/F E B R UA RY 2018 | P EN N S YLVA N IA D EN TA L J O U R N A L