Disclosure and Consent

Anesthesia and/or Perioperative Pain Management (Analgesia)

To be filled out on the day of the appointment

TO THE PATIENT:

You have the right, as a patient, to be informed about 1) the recommended anesthesia/analgesia to be used and 2) the risks related to anesthesia/analgesia. This disclosure is designed to provide you this information, so that you can decide whether to consent to receive anesthesia/analgesia in the perioperative period (meaning shortly before, during and shortly after a procedure). Please ask your physician/health care provider any remaining questions you might have before signing this form.

"*" indicates required fields

The plan is for the anesthesia/analgesia to be administered by Timothy J. Leishman, DMD

I, the patient or legally authorized representative, consent to the above provider administering the anesthesia/analgesia during the dental treatment.

Signature*

Planned Anesthesia/Analgesia Methods & Initials

GENERAL ANESTHESIA – injury to vocal cords, teeth, lips, eyes; awareness during the procedure; memory dysfunction/memory loss; permanent organ damage; brain damage.

LOCATION: nerve damage; persistent pain; bleeding/hematoma; infection; medical necessity to convert to general anesthesia; brain damage.

Location:

Planned Anesthesia/Analgesia Methods & Initials

DEEP SEDATION – memory dysfunction/memory loss; medical necessity to convert to general anesthesia; permanent organ damage; brain damage.

MODERATE SEDATION – memory dysfunction/memory loss; medical necessity to convert to general anesthesia; permanent organ damage; brain damage.

Additional comments/risks:*

Additional comments/risks:

Check if applicable and have the patient/legally authorized representative initial.

PRENATAL/EARLY CHILDHOOD ANESTHESIA

PRENATAL/EARLY CHILDHOOD ANESTHESIA – potential long-term negative effects on memory, behavior, and learning with prolonged or repeated exposure to general anesthesia/moderate sedation/deep sedation during pregnancy and in early childhood.

Signature*

Granting of Consent for Anesthesia/Analgesia

In signing below, I consent to the anesthesia/analgesia described above.

I have been given an opportunity to ask questions about alternative forms.
I understand the steps that will occur during administration.
I understand the risks and hazards involved.

Granting of Consent for Anesthesia/Analgesia*

I believe I have enough information to give this informed consent.*

I certify this form has been fully explained and all blank spaces are complete.*

I have read the form or had it read to me.*

I understand the information on this form.*

If any statement is not true, speak with your physician or health care provider before continuing.

Patient/legally authorized representative signature*

Print name*

First

Relationship to patient (if representative)*

Date*

Time*

Witness signature*

Dental clinic*

Other clinic

Address*

City * State * Zip Code*

Forms

Disclosure and Consent

To be filled out on the day of the appointment

TO THE PATIENT:

Administration of Anesthesia/Analgesia

Types of Anesthesia/Analgesia Planned and Related Topics

Check planned anesthesia/analgesia method(s) and have the patient/legally authorized representative initial.