location_on 805 Development Dr ❘ Kingston, Ontario K7M 4W6
call(613) 389-8660
mail reception@davidgouettdentistry.com

Address

805 Development Dr, Kingston, ON K7M 4W6

Tel: 613-389-8660 | Fax: 613-389-9003

# INFORMED CONSENT FOR INTRAVENOUS
CONSCIOUS SEDATION

Patient Name:
Treatment:

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
Date
Signature of Witness
Date