David Gouett Dentistry ADDRESS:
805 DEVELOPMENT DR, KINGSTON, ON K7M 4W6
TEL: 613-389-8660
EMAIL: reception@davidgouettdentistry.com

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]
GOUETT DENTISTRY
Architectural Excellence in Restorative Care.
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