You have elected to have intravenous sedation for a dental/surgical procedure. A catheter will be placed in a vein in your arm or hand. Drugs will be administered making you relaxed, sleepy and even causing some level of amnesia. You will not be unconscious. Local anesthetics may be used in addition to control pain during surgery. Because of your sedated condition, you must adhere to the following recommendationsfor your safety and recovery:
I understand my responsibilities as listed above. I agree to adhere to my responsibilities as a patient.
, acknowledge that Dr. Jonathan Pluid has explained to me that I will have a dental procedure performed under IV moderate sedation. By definition, IV moderate sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or by light, tactile stimulation.
It has been explained to me that all forms of anesthesia involve some risks and no guarantees or promises can be made concerning the results of my procedure or anesthesia. Although rare, unexpected complications can occur with sedation including: infection, bleeding, drug reactions, blood clots, loss of sensation, loss of limb function, paralysis, stroke, brain damage, heart attack or death. I understand that these risks apply to all forms of anesthesia and I give consent for Dr. Jonathan Pluid to perform IV moderate sedation.
Be present in the facility before and after completion of the operation: You are required to be present when checking the patient in for his/her procedure. Please be available during the entire procedure time should we finish early. The patient will be released to your care upon completion of the procedure and sufficient anesthesia recovery.
Don't allow the patient to drive: You will be required to drive the patient home and stay with them for a minimum of 8 hours post procedure. Patients who have had sedation should not drive for the rest of the day.
Please relay any post-opinstructions you received from the provider to the patient: The medications given will cause amnesia and they most likely will not remember any instructions given to them by our staff upon completion of the procedure.
I understand my assigned role and responsibilities as listed above. I agree to adhere to my responsibilities as a patient escort.