Pre and Post Sedation Form

Pre and Post Sedation Form
The purpose of this document is to provide information and instructions for patients and caregivers leading up to and following conscious sedation administered as part of dental treatment. If you have any questions or concerns, please ask while attending at the dental office or by phoning the number provided.
Patient Information and Instructions
- NO food or water for 8 hours prior to your appointment. Regularly taken medications are allowed with water only.
- Do not consume sedatives for 24 hours before or after your appointment
- Do not consume stimulants for 24 hours before or 12 hours after your appointment (including alcohol, caffeine or other caffeinated beverage, nicotine, or recreational drugs)
- Do not drink grapefruit juice or eat any grapefruit product for 24 hours before appointment
- Consult your dentist before your appointment if there is a possibility that you are pregnant or if you are lactating
- Advise your dentist or their assistant of any known allergies or previous reactions to drugs
- Advise your dentist or their assistant of any recent changes in health or onset of symptoms of illness, especially for fever or respiratory illnesses such as cold or flu
- Wear loose, comfortable clothing to your appointment
- Removal all jewellery and leave at home
- You MUST have a responsible adult (18 years or older) bring you to and take you home from your appointment
- You MUST have a responsible adult with you until you are completely recovered from the effects of the sedation
- You MUST remember to drink plenty of fluids, including at least 2-3 glasses of water after you get home from your appointment
- NO driving for 24 hours after your appointment
- NO operating machinery hazardous devices or appliances for 24 hours after your appointment
- NO walking up or down stairs alone until completely recovered from sedation
- NO important decisions (no work) for 24 hours after appointment
- NO food or water for 8 hours prior to appointment. Discuss regular medications with your respective dentist.
- Take prescribed medications with a sip of water unless instructed otherwise
Please follow these pre- and post-operative instructions and take necessary medication as prescribed by your dentist. Should you have any questions or concerns, contact our office.
Today's Date*
Patient Name*
First Name Last Name
Signature*
Sedation time prior to appointment*

Approximately how minutes will you take a pill before your appointment.
Sedation duration*

Approximately how long will my sedation treatment last?

Pre and Post Sedation Form

Pre and Post Sedation Form

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