CHILDREN'S DENTISTRY OF WESTERLY RI & WAKEFIELD RI

Nitrous Oxide Form

Your Information:

First Name

Last Name

Phone

Child's Information:

Child's Full Name

Child's DOB

Recommendation of Nitrous Oxide:
I recommend using Nitrous Oxide during 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.

Please read each bullet below, ask any related questions, and check off the box indicating that you understand.

I understand that nitrous oxide will only provide relaxation and that local anesthesia may still be necessary.*

I understand that nitrous oxide is not a "cure-all" and may not be compatible with my child's needs and that absolute success cannot be guaranteed.

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 lightheaded feeling.

I accept and understand that the alternatives to Nitrous Oxide administration are:

No Nitrous Oxide. The necessary procedure is performed and local anesthetic ("Novocaine") is used as needed.*

General Anesthesia that requires that the patient to be treated at a hospital.

Acknowledgment:
Please check off the required acknowledgment statements below before submitting this form.

I have been informed of the benefits, risks, and alternatives regarding the administration of nitrous oxide to my child.

I am aware that the per-visit fee of $100 for nitrous oxide is non-refundable regardless of the visit outcome.

I am aware that I may not take videos or photographs of my child during treatment.

I am aware that the failed appointment fee for a nitrous oxide appointment is $100.

I am aware of the 48-hour cancellation policy for nitrous oxide appointments. Cancellation must be made 2 business days prior to the appointment to avoid a $100 fee.

Consent & Certification:
Please check off the required consent & certification statements below before submitting this form.

I consent and authorize Dr. Capalbo and/or Dr. Downey to use nitrous oxide (laughing gas) during the treatment of my child.

I certify that the information provided in this form is correct to the best of my knowledge. I also certify that I am the person who I claim to be and I am not falsely representing another individual.

Signature

When should I schedule my child’s first dental visit?

As soon as your child has teeth, there is potential for tooth decay! Schedule your child’s first dental visit with us by his/her first birthday or within 6 months of the first tooth erupting. We’re your top Rhode Island pediatric dentists located in Westerly, RI & Wakefield, RI, caring for Rhode Island and southeastern Connecticut families. We accept most insurance plans in both offices, including:

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Dentist in Westerly RI | Dentist in Wakefield RI | Rhode Island Pediatric Dentists | Southeastern Connecticut Pediatric Dentists

CHILDREN'S DENTISTRY OF WESTERLY RI & WAKEFIELD RI

Nitrous Oxide Form

Contact Children's Dentistry of Westerly & Wakefield

Children’s Dentistry – Westerly, RI

401-596-8720

Children’s Dentistry – Wakefield, RI

401-792-4664

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