Patient name : ____________________________________________________ Patient ’ s Weight : _________________
Alternative Treatments , Not Limited to the Following :
Date of Birth : ____________________
If a particular level of anesthesia does not relieve the patient ’ s anxiety or pain , in the dentist ’ s clinical judgment and if the individual patient can tolerate it , another level of anesthesia may be needed . Not every dental office or dentist is equipped or trained to administer every type of anesthesia . It may be necessary to bring an anesthesiologist into the dental operatory or refer the patient to another facility or to another dentist who has the appropriate equipment or credentials . Those types of services may result in additional charges .
For All Female Patients
Because anesthetics , medications and drugs maybe harmful to the unborn child and may cause birth defects or spontaneous abortion , every female must inform the anesthesiologist and dentist if she could be or is pregnant . Anesthetics , medications and drugs absorbed in the mother ’ s milk may temporarily affect the behavior of the nursing baby . In either case , the anesthesia and treatment may be postponed .
For All Patients
I have been given the opportunity to ask questions about the recommended method of anesthesia and believe that I have sufficient information to give my consent as noted below .
I give my consent for the use of _________________________________ anesthesia , as explained above when Dr . _________________________ determines it is indicated in the treatment of __________________________.
( Patient ’ s name )
I refuse to give my consent for the proposed anesthesia .
I have been informed of and accept the consequences if no treatment is administered because I do not agree to the proposed anesthesia modality . The consequences include , but are not limited to : tooth loss , infection , decay and the need for additional restorations .
Patient or Patient ’ s Representative ’ s Signature
Date
I attest that I have discussed the risks , benefits , consequences and alternatives of anesthesia with ____________________ ( Patient or Patient ’ s Representative ) who has had the opportunity to ask questions , and I believe understands what has been explained .
Dentist ’ s Signature Date
Witness ’ s Signature Date
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