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
Please read each bullet below, ask any related questions, and check off the box to indicate that you understand.
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Item 9(Required)
Consent(Required)
Clear Signature
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