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Informed Consent for Nitrous Oxide Sedation

Informed Consent for Nitrous Oxide Sedation

Potential Complications
Although rare and temporary, adverse effects may occur. These include, but are not limited to:
• tingling sensation in the fingers, toes, cheeks, lips, tongue, and may even involve the entire head;
• heavy feelings in the legs followed by a floating feeling;
• perceived resonating voice that has a hyper nasal tone;
• a warm or hot feeling in the body, and hot flushes in the face;
• uncontrollable laughter and/or talking;
• feelings of nausea and/or vomiting;
• agitation or irritability;
• sluggishness in motion;
• slurring or words.

There are certain medical conditions that contraindicate the use of Nitrous Oxide. These include:
• congestive heart failure;
• chronic obstructive pulmonary disease (COPD);
• chronic bronchitis;
• emphysema;
• chronic asthma;
• bronchiectasis;
• pregnancy;
• hepatitis B or C;
• tuberculosis;
• macrocytic anemia;
• immune Diseases;
• respiratory disease;
• middle ear infections;
• history of substance abuse;
• claustrophobia.
Be sure to inform your dentist if you have any of the aforementioned medical conditions.

Alternative Treatment Options
Other options for sedation include:
• Oral sedation (e.g. benzodiazepines)
• Other inhalation sedation (e.g. Penthrox)
• Intravenous sedation
• General anaesthetic
The dentist can provide you with more information on these sedation modalities.

The cost of administering Nitrous Oxide treatment is as outlined in the attached treatment plan. Full payment is required on the day of the appointment.

• I have read and understand the conditions and information in this Consent Form.
• I have discussed the information contained in the Consent Form concerning treatment under Nitrous Oxide with my dentist.
• I have had explained to me the cost of the treatment and I accept responsibility for that cost.
• I authorise my dentist to provide me with treatment under Nitrous Oxide.