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# Informed Consent for Intravenous Conscious Sedation Official Clinical Consent Record Submission
Patient Name: | [Patient Name Response]
Treatment | [Treatment Description Response]
Intravenous conscious sedation is a method of helping me relax and become more comfortable during my dental treatment. Although I will not be asleep, I may not remember precisely what was done. This is accomplished with the dentist starting an intravenous line in my arm or back of my hand with a small needle to slowly titrate (add small amounts) of a medication to make me more comfortable and less anxious. Blood pressure and pulse monitors will be attached to help assure my safety. I will have the opportunity to ask questions and will alert the dentist of any allergies or significant medical history. I will provide an adult escort who will accompany me home after early recovery. I will refrain from driving, operating machinery and drinking alcohol for the following 24 hours.
Signature of Patient [Digitally Endorsed by Patient]
Date [mm/dd/yyyy]
Signature of Witness [Digitally Endorsed by Witness]
Date [mm/dd/yyyy]
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