I, _______________________________, hereby authorize and request duly licensed anesthesiologists and nurse
(self or legal guardian)
Anesthetist, ____________________________________________, associated with Apex Dental Anesthesia to perform the
Anesthesia on ___________________________ as previously explained to me and any other procedure deemed necessary or ( patient)
advisable as a corollary to the planned anesthesia. I consent, authorize and request the administration of such anesthetic or anesthetics (local to general) by any route that is deemed suitable by the anesthesiologist, who is an independent contractor and consultant. It is the understanding of the undersigned that the anesthesiologist will have full charge of the administration and maintenance of the anesthesia and this is an independent function from the surgery/dentistry.
The most frequent side effects of any IV anesthesia are drowsiness, nausea/vomiting, and phlebitis. Most patients remain drowsy or sleepy for the remainder of the day following their surgery. As a result, coordination and judgment will be impaired for as long as 24 hrs. It is recommended that adults refrain from activities such as driving, and children remain in the presence of a responsible adult during this period. Nausea and possible vomiting following anesthesia will occur in 10-15% of patients. Phlebitis is a raised, tender, hardened, inflammatory response at the intravenous site which usually resolves with local application of warm moist heat. However tenderness and a hard lump may be present up to a year.
I have been informed and understand that rarely there are complications of anesthesia including but not limited to: pain, hematoma, numbness, infection, swelling, bleeding, discoloration, nausea, vomiting, allergic reaction, pneumonia, stroke, brain damage, heart attack and death. I further understand and accept the risk that complications may require hospitalization. I have been made aware that the risks associated with local anesthesia, conscious sedation and general anesthesia vary. Of these three, local anesthesia is usually considered to have the least risk, and general anesthesia the greatest risk. However, it must be noted that local anesthesia sometimes is not appropriate for every patient and every procedure.
I understand that anesthetics, medications, and drugs may be harmful to the unborn child and may cause birth defects or spontaneous abortion. Recognizing these risks, I accept full responsibility for informing the anesthesiologist of the possibility of being pregnant or a confirmed pregnancy with the understanding that this will necessitate the postponement of the anesthesia. For the same reason, I understand that I must inform the anesthesiologist if I am a nursing mother.
Since medications, drugs, anesthetics, and prescriptions may cause drowsiness and lack of coordination, which can be increased by the use of alcohol or other drugs, I have been advised of the necessity of direct parental supervision of my child for twenty-four hours or longer until fully recovered from the effects of the anesthetic, medications and drugs that have been given to me or my child. I have been advised of the necessity of direct parental supervision of my child for twenty-four hours following their anesthesia.
I have been fully advised and completely understand the alternatives to sedation and general anesthesia. I accept the possible risks, side effects and dangers of anesthesia. I acknowledge the receipt of and understand both the pre-operative and post-operative anesthesia instructions. It has been explained to me and I understand that there is no warranty and no guarantee as to any result and or cure. I have had the opportunity to ask questions about my child’s or my anesthesia, and I am satisfied with the information provided to me. It is also understood that the anesthesia services are completely independent from the operating dentist’s procedure. The anesthesiologist assumes no liability from the surgery/dentistry performed while under anesthesia and that the dentist assumes no liability from the anesthesia performed.
Signed _________________________________________ Relationship _________________________________
Print Name ______________________________________ Witness _____________________________________
Anesthesiologist Signature ________________________________________ Date: _________________________________
If you have any concerns or questions before or after your anesthesia appointment, please call: