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Local anesthetic:
It has been explained to me that there are certain risks to having
local anesthetic or "shots" with a needle. They include allergic
reactions, possible death, electric shock. I understand there can be
a numbness in my lip or tongue or chin that may be permanent in rare
cases. Further I realize that if epinephrine is used it can cause
heart flutter and acute anxiety. Local anesthetic can cause drooping
of the eyelid and side of the face known as a Bell's Palsey effect.
At the injection site there can be bruising , swelling, or a
hematoma.
Initials here___________
Nitrous Oxide (relaxing gas) While relaxing gas works well for most
patients some can have the following reactions: Nausea, vomiting,
dizziness, inability to drive a car, hallucinations, and death.
Initials here___________
Intravenous Sedation (twilight sleep or sleep dentistry) In order to
have IV sedation, I must have had nothing to eat for 6 (six) hours
prior to the appointment. I can only have a sip of water one hour
prior to the visit if I take an oral medication. I understand the
following risks are associated but not limited to IV sedation:
nausea, vomiting, and death. Sore arms from needle placement as well
as bruising and in rare cases sloughing of the skin in the area of
the IV needle. If drug reversal agents are used headaches can
result. I understand oxygen may be used in relation to the drugs. It
is possible to have an allergic reaction or an over reaction to the
medication. I understand that I am to wear clean loose comfortable
clothing such as sweats and a short sleeve shirt, and I am to wear
comfortable walking shoes such as tennis shoes, or other flat shoes.
After the appointment I must have a ride home and an escort. I
understand that I am not to drive for 24 hours.I have not eaten for
six hours prior tothis visit.
Initials here___________
Electronic Anesthesia The advantage of electronic anesthesia is that
there are no chemicals injected in the body. The disadvantages are
electric shock and the anesthesia is not as profound as local
anesthetic. It is not to be used in conjunction with pace makers.
There is a learning curve to get improved performance.
Initials here___________
Risks associated with the type of anesthesia I have elected have
been explained to me. All my questions have been answered and I
permit Dr. Starkey and his staff to provide the anesthesia I have
initialed.
Patient signature ______________________________Date__________
Witness signature ______________________________ |
