I UNDERSTAND that undergoing I.V. SEDATION/ANESTHESIA includes possible inherent risks such as, but not limited to the following:

1. Complications due to drugs and anesthesia, which include but not limited to: tenderness, bruising, nausea, vomiting, swelling, bleeding, infection, numbness, allergic reaction, stroke, and heart attack. Some of these complications, although rare, may require hospitalization and may even result in death.
2. Bruising or tenderness of I.V. induction site may occur. Some sedative agents may cause a burning or itching sensation in the wrist or arm during induction. Edema may be caused when excess I.V. sedation fluid enters surrounding tissues and may take several days to resolve. Tenderness edema can be treated with warm moist heat applied to the site.
3. Need for limitations of food and drink. I understand that the patent must refrain from any food or drink after midnight for a morning appointment. Prior to an afternoon appointment, the patent is limited to a light breakfast no later the six hours before treatment.
4. Changes in health are important, including fevers or cold. I am expected to convey this information to the dentist prior to a planned appointment when I.V. sedation/anesthesia are involved.
5. A responsible adult must accompany the patent at the time of discharge, and I understand that the patent must not drive a vehicle or take a bus or taxi after undergoing I.V. sedation/anesthesia.
6. Women: Anesthetics, medications and drugs may be harmful to an unborn child and may cause birth defects or spontaneous abortion, and I accept full responsibility for informing the dentist or attending anesthesiologist or anesthetist of a suspected or confirmed pregnancy. Scheduling: This appointment requires clinical preparation and private personalized scheduling with this we require $100.00 booking fee that can be applied to any co-pays due only if the following does not apply: If appointment is failed or cancelled without 24 hours’ notice is fee is non-refundable. If sedation is attempted, but unsuccessful for any reason, fee is non-refundable.

INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature purposed of I.V. sedation/anesthesia and have received answers to my satisfaction. I do voluntarily assume any and all possible risks, including the risk of substantial harm, if any, or even death which may be associated with any phase of receiving I.V. sedation/anesthesia in hopes of obtaining the desired results, which may not be achieved. NO guarantees or promises have been made to me concerning my signing this form, I am freely giving my consent to allow and authorize the below doctor and/ or his/her associates to render and treatment necessary or advisable to my dental conditions, including any and all anesthetics and/or medications, for my own benefit or the benefit of my minor child or ward.