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
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
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.