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

Sedation Informed Consent

REQUEST FOR ANESTHESIA AND SEDATION

Dr. Brian Kumer

It is our moral and legal obligation to give you the information necessary to make an educated decision in requesting treatment. The benefits of therapy are usually greater than the risk, but there are risks. There are events that can occur with any type of treatment. These risks are being explained to inform and educate you, not to alarm you. Eliminating surprises will make your care go more smoothly. As with any dental procedure you must advise us of your medical status including a complete disclosure of all medications and/or drugs that you are currently taking with special notice to us if you are pregnant or have glaucoma.

Rare occurrences include any event that might be remotely possible but unlikely to occur. These include: allergic reaction to drugs, which range from hives to heart failure. Drug reactions are side effects and treated as such. The office staff has had training in managing these potential problems.

Medications, drugs, anesthetics and prescriptions may cause drowsiness and lack of awareness and co-ordination, which can be increased by the use of alcohol or other drugs.

DO not operate any vehicle, automobile or hazardous device for 24 hrs following your surgery. Your judgment and work performance can be altered by pain medication or the sedative agents and you should plan accordingly. Your signature below certifies.

You consent and request for Dr. Brian Kumer or any dentist working with him/her to perform the following treatment.

Full treatment as described in my treatment plan.

You understand that on rare occasions, individual patient differences can result in relapse of a condition in spite of our efforts to provide optimum care. In this event you understand the selective re-treatment may become necessary.

Your agreement to the administration of local anesthesia, nitrous oxide/oxygen and/or oral sedation as discussed with the dentist.

Your authorization for the dentist to use best judgment in managing unforeseen conditions, which unexpectedly arise during the course of the procedure.

Your understanding that lack of co-operation with our recommendation during your care may result in less than optimum result.

That you read and write English, understand the above information and have opportunity to review and discuss it as well as your health history including any serious problems or injuries. That all statements requiring insertion or completion were filled in, and inapplicable paragraphs, if any were stricken before you sign. That you are both mentally and physically competent to give this content.

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

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