Dentistry On 66

CONSENT FOR LAUGHING GAS (NITROUS OXIDE)

The purpose of the consent is to provide the opportunity for patients (or their parents/guardians) to understand and give permission for the use of nitrous oxide when provided along with dental treatment.

  • I except financial responsibility for administration of the Nitrous Oxide
  • I am aware that the actual cost may exceed the estimated cost and may not be covered by my insurance plan
  • I accept and understand that the purpose of Nitrous Oxide is to minimize pain and anxiety. I also accept and understand that the use of Nitrous Oxide to eliminate anxiety cannot be guaranteed.
  • I accept and understand that the alternative to Nitrous Oxide are:
    1. Local anesthetic alone
    2. IV sedation
    3. General Anesthetic
  • I accept the common risks may include but are not limited to:
    1. Nausea/vomiting/upset stomach
    2. Agitation
    3. Temporary visual or auditory hallucinations.

Contraindications of use of nitrous may include:

  1. CODP
  2. Sinus Infection
  3. Nasal Obstruction (cold, upper respiratory infection, allergies etc)
  4. Narrow angle glaucoma
  5. Bowel obstruction
  6. Middle ear infection
  7. Pneumotharox
  8. Recent retinal surgery

By signing, I or the patient for whom I act as guardian/POA, understand that I am aware of the use of Nitrous Oxide
and its contraindications and accept its costs, benefits and limitations. I may elect to discontinue its use at any time.

d066 Gas
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