Forms

Please read the following forms before coming in for your dental treatment.
PRE-ANAESTHESIA QUESTIONNAIRE FORM NEEDS TO BE FILLED OUT IN
“Oral Sedation” AND “IV Sedation” SECTIONS

Pre Sedation Instructions

PRESEDATION INSTRUCTIONS

This type of sedation will produce a dream like state. Most people will become indifferent to the dental procedure after the sedation takes effect. The sedation is given Intravenously Please follow the instructions below

1) Do not eat or anything 8 hours prior to your appointment or drink anything other than water, clear apple juice, ginger ale, clear tea or black coffee (NO MILK or CREAM) for 3 hours prior to appointment. Take the medication prescribed by your M.D; as long as its 3hrs prior to your appointment.

2) Do not wear contact lenses to the appointment.

3) No alcohol for 12 hrs. before your appointment.

4) Please wear a short sleeved shirt. No nail polish, including clear.

5) You must have a responsible person with you to escort you home and be given post sedation and surgical instructions. You may not take public transit or a taxi home unescorted!

6) Do not drink grapefruit juice 24hrs prior to surgery.

7) Please advise our office of any medications that you are taking whether prescribed or over the counter.

8) Contact us prior to your appointment if there has been a change to your general health.

IF YOU HAVE ANY OTHER QUESTIONS PLEASE CALL

Dr. Brian Kumer

416 605-0008

Post Sedation Instructions

POST SEDATION INSTRUCTIONS

1) Do not drive or operate hazardous equipment for 24hrs after sedation.

2) A responsible person should remain with the patient until they are fully recovered from the effects of sedation.

3) Patients must not go up or down stairs unescorted for 24hrs.

4) No unattended bath or shower for 24 hrs.

5) Diet is restricted by surgical procedure not the sedation.

6) Drink plenty of fluids, 1.5-2 litres per day in the first three to four days.

7) Always hold patients arm when walking. Alert and sleepy patients need to be treated in the same manner.

8) Don’t use any pillows for the first night.

9) No alcohol for 24hrs

10) Do not sign any important or legal documents for 24hrs.

11) Call if you have any questions or concerns. If you feel that your symptoms warrant a physician and you are unable to reach us go to the nearest emergency room immediately.

Following most surgical procedures there may be pain. You will be provided with a prescription for medication that is most appropriate for you. Antibiotics and Pain killers are the usual medications being prescribed, although antibiotics are not always required. Please follow the directions on the bottle of the medications. If you are taking any other medications and are concerned about drug interactions speak to the dentist or your pharmacist.

DR BRIAN KUMER

(416) 605-0008

IV sedation consent form

Dr. Brian Kumer DDS

Consent for I.V. Conscious Sedation

This form is provided to inform you of the choices and risks involved in having I.V Conscious Sedation.

The most frequent side effects of any intravenous sedatives are drowsiness, nausea and phlebitis.Most patients remain drowsy or sleepy following their surgery for the remainder of the day.As a result, coordination and judgement will be impaired.It is crucial that adults refrain from activities such as driving, and children remain in the presence of a responsible adult.Phlebitis is a raised, tender, hardened, inflammatory response at the intravenous site.The inflammation usually resolves with the application of a warm towel and anti-inflammatory medication; however, tenderness and a hard lump may be present up to a year.

I have been informed and understand that occasionally there are complications of the drugs IV Sedation including but not limited to: pain, hematoma, numbness, infection, swelling, bleeding, discolouration, nausea, vomiting, allergic reaction, skin rash, respiratory depression/arrests, seizures, hallucinations,I have been made aware the risks associated with local anesthesia and I.V. Conscious Sedation, it must be noted that local anesthesia isappropriate for almost every patient and every procedure.Nerve damage from local anesthesia administration usually resolves, however, this may take over one year to heal.Nerve damage from local anesthesia administration may also be permanent.

I understand that sedation medications, and drugs maybe harmful to the unborn child and may cause birth defects or spontaneous abortion.Recognizing these risks, I accept full responsibility for informing Dr. Brian Kumer of the possibility of being pregnant or a confirmed pregnancy with the understanding that this will necessitate the postponement of the sedation for the same reason, I understand that I must inform Dr. Brian Kumer if I am a nursing mother.

Sedation medications and, drugs, and prescriptions may cause drowsiness that can be increased using alcohol or other drugs.I have been advised not to operate any vehicle or hazardous devise for at least twenty-four hours, or until fully recovered from the effects of the medications, and drugs.I have been advised not to make any major decisions until after full recovery from the sedation.Parents are advised of the necessity of direct parental supervision of their child for twenty-four hours following the sedation.

I have been advised of and completely understand the risks, benefits, and alternatives of local anesthesia and conscious sedation.I accept the possible risks.I acknowledge the receipt of and understand both the preoperative and post-operative sedation instructions.It has been explained to me and I understand that there is no warranty and no guarantee as to any resultI authorize the exchange and sharing of my personal information between the treating doctor’s office and Dr. Brian Kumer.

I consent to the administration of IV Conscious Sedation and other drugs as deemed necessary.I understand and agree to follow the “Patient Instructions” information as previously given to me.I have been explained the proposed treatment as presented to me.I am aware of the options to treatment; the associated risks and I have been given the opportunity to ask questions.I agree to be responsible for any associated fees.

I certify that I fully understand the terms within the above consent.

I can read and write English ____ Yes

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