Nitrous Consent Form

NITROUS OXIDE – INFORMATION AND CONSENT
Introduction
Nitrous oxide is a colorless, slightly sweet gas that is used during dental treatment for relaxation and anxiety relief. When inhaled, it can induce feelings of sedation and euphoria. It also can produce sensations of drowsiness, warmth and tingling in the hands, feet and/or around the mouth. In the dental setting, it will not induce unconsciousness. You will be awake, aware of your surroundings and able to respond rationally to inquiries and directions. You will be able to swallow, talk and cough as needed.
Contradictions*
Please let us know if you have any of the following medical condition, because we may not be able to safely use nitrous oxide
Pre-Operative Guidelines
- Nitrous oxide is administered through a nasal mask. You must be able to breathe through your nose (blocked nasal passages, deviated septum, colds, etc. can impede the effective administration of nitrous oxide).
- Avoid eating for at least four (4) hours prior to the dental treatment. Nitrous oxide can cause “stomach butterflies” or nausea, which may result in vomiting.
- Avoid caffeinated products before coming in for treatment.
- Do not take any antidepressants or other sedatives on the day of your appointment unless approved or prescribed by your dentist.
Instructions During Nitrous Oxide Use
Your mask must remain firmly in place during the entire period. Do not breath through your mouth. Breathe through the nose only. Notify the doctor if you are having trouble with breathing through your nose. No talking is allowed while nitrous oxide is being used. Talking blows nitrous oxide into the room, lessening the desired effect for you, and exposing the dental staff to the nitrous effects.
Post-Operative Guidelines
Recovery from nitrous oxide sedation is rapid. The gas will be flushed from your system with oxygen. If you feel dizzy after sedation, remain seated and the sensation should pass in a few minutes. Do not leave the office until your head feels clear, and you are able to function (walk and drive) safely.
Risks of Nitrous Oxide
There are minimal risks associated with this sedation procedure. You may feel nauseated, dizzy, drowsy or claustrophobic during or after sedation
Alternatives to Nitrous Oxide
You may choose not to use nitrous oxide and complete your dental treatment without any treatment for anxiety. You may be referred to a specialist for deeper sedation if you feel you require it. If your dentist feels this is an option for you, you may choose to take an oral sedative or a pill that will relieve your anxiety. This consent is valid for a period of twelve (12) months. I may withdraw my consent at any time.
Acknowledgement*
I acknowledge and agree that the nature of nitrous oxide has been explained to me and that I have read the above information and have been informed of the benefits and risks of providing such treatment. I have had the opportunity to ask questions and all such questions have been answered to my satisfaction. I have given a full and accurate report of my medical history, including allergies, conditions, medications and history of illness. I authorize and agree to undergo the nitrous oxide treatment described above.
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Nitrous Consent Form

NITROUS OXIDE – INFORMATION AND CONSENT

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