IV Sedation Informed Consent

IV Sedation Informed Consent Form



I understand that undergoing IV sedation includes possible inherent risks such as, but not limited to the following:

  1. Complications due to drugs which include but are not limited to nausea, vomiting, swelling, bleeding, infection, numbness, allergic reaction, and heart attack. Some of these complications, although rare, may require hospitalization and may even result in death.

  2. Bruising or tenderness of the IV induction site may occur. Some sedative agents may cause a burning or itching sensation in the place the IV administered. Swelling may be caused from excess IV fluid entering surrounding tissues and may take several days to resolve. Tenderness, bruising, or swelling can be treated with warm moist heat applied to the site.

  3. Need for limitation of food and drink. I understand that the patient must refrain from any food or drink at least 6 hours prior to the I.V. sedation.

  4. Changes in health are important, including fevers or colds. I am expected to convey this information to the dentist prior to a planned appointment when IV sedation is involved.

  5. A responsible adult must accompany the patient at the time of discharge. I understand that the patient must not drive a vehicle or take a bus or taxi after undergoing IV sedation. I will be monitored by the responsible adult or an escort adult for at least 6 hours post-operatively.

  6. Women: Anesthetics and other medications may be harmful to an unborn child and may cause birth defects or spontaneous abortion. I accept full responsibility for informing the dentist or attending anesthetist of a suspected or confirmed pregnancy.

  7. I have been given the opportunity to ask any questions regarding the nature and purpose ofIV sedation and have received answers to my satisfaction. I do voluntarily assume any and all possible risks, including the risk of substantial harm, if any, or even death which may be associated with any phase of receiving IV sedation in hopes of obtaining the desired results, which may or may not be achieved.

  8. No guarantees or promises have been made to me concerning my recovery and results of the treatment to be rendered.

  9. The fees for this service have been explained to me and are satisfactory. By signing this form, I am freely giving my consent to allow and authorize Dr. Kwan M. Lee to render any treatment necessary or advisable to my dental conditions, including any and all anesthetics and medications for my own benefit or the benefit of my minor child or ward.

Patient Signature


Escort Signature

Witness Signature

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