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Nitrous Oxide Consent Form
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CHILDREN'S DENTISTRY OF WESTERLY RI & WAKEFIELD RI
Nitrous Oxide Consent
Nitrous Oxide Consent Form
I recommend using Nitrous Oxide during the treatment of your child; Nitrous Oxide is breathed through a nasal mask, and after a state of relaxation is reached, local anesthesia ("Novocaine" or "the shot") will be administered if required for the procedure.
Patient Name
First
Last
Please read each bullet below, ask any related questions, and check off the box to indicate that you understand.
Item 1
(Required)
I understand that Nitrous Oxide will only provide relaxation and that local anesthesia may still be necessary.
(Required)
Item 2
(Required)
I understand that Nitrous Oxide is not a ‘cure-all’ and may not be compatible with my child’s needs and that absolute success can not be guaranteed.
(Required)
Item 3
(Required)
I understand that the administration of nitrous oxide carries with it certain risks and potential unpleasant side effects. These include, but are not limited to shivering, nausea and vomiting, or a 'light headed' feeling.
(Required)
Item 4
(Required)
I accept and understand that the alternatives to Nitrous Oxide administration are 1) No Nitrous Oxide. The necessary procedure is performed, and local anesthetic ("novocaine") is used as needed, or 2) General Anesthesia which requires that the patient to be treated at a hospital.
(Required)
Item 5
(Required)
I have been informed of the benefits, risks and alternatives regarding the administration of Nitrous Oxide to my child.
(Required)
Item 6
(Required)
I am aware that the per-visit fee of $125 for Nitrous Oxide is non-refundable regardless of the visit outcome.
(Required)
Item 7
(Required)
I am aware that I may NOT take videos or photographs of my child during treatment.
(Required)
Item 8
(Required)
I am aware that there is a failed appointment fee of $80. Cancellations made less than 2 business days prior to a Nitrous Oxide appointment will incur an $80 fee.
(Required)
Item 9
(Required)
I am aware that my child is not to eat or drink 2 hours prior to the administration of Nitrous Oxide.
(Required)
Consent
(Required)
I consent and authorize the use of Nitrous Oxide (laughing gas) during the treatment of my child.
Parent/Guardian's Signature
Date
MM slash DD slash YYYY
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