The purpose of this Informed Consent Form is to provide an opportunity for patients (and/or their parents or
guardians) to understand and give permission for the use of nitrous oxide when provided along with dental treatment.
I understand that nitrous oxide is commonly called laughing gas and provides relaxation, although I will be awake,
fully conscious, aware of my surroundings, and able to respond rationally to inquiries and directions.
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I accept and understand that the use of nitrous oxide is not required to provide the necessary dental care.
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I accept and understand that the purpose of nitrous oxide is to make it more comfortable for me to receive
the necessary dental care with less pain and/or anxiety. I also accept and understand that the use of
nitrous oxide has limitations and risks, and absolute success cannot be guaranteed.
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I accept and understand that nitrous oxide will be administered by way of the inhalation route.
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I accept and understand that the alternatives to nitrous oxide are:
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No nitrous oxide: The necessary procedure is performed under local anesthetic only.
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Anxiolysis: A pharmacologically induced state of consciousness where an individual is awake but has
decreased anxiety to facilitate coping skills, retaining interactive ability.
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Oral conscious (or minimal) sedation: Sedation via pill form that will put me in a minimally to
moderately depressed level of consciousness.
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Intravenous (1.V.) conscious (or moderate) sedation: Sedation via the intravenous route that will
put me in a minimally to moderately depressed level of consciousness.
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General anesthesia: Also called deep sedation, a patient under general anesthetic has no awareness
and must have his/her breathing temporarily supported. General anesthesia is appropriate for more
invasive procedures.
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The use of nitrous oxide has been completely explained to me, including all risks involved. I have been
fully informed that temporary complications may include, but are not exclusive of: tingling in the fingers,
toes, cheeks, lips, tongue, head or check area; heaviness in the thighs and/or legs, followed by a lighter
floating feeling; resonation in the voice or presence of a hypernasal tone; warm feeling throughout body,
with flushed cheeks; fits of uncontrollable laughter or giddiness; detachment or disassociation from
environment may occur; intense and uncomfortable warm and/or hot feeling throughout body; lightweight or
floating sensation with an accompanying "out of body" sensation; sluggishness in motion and slurring and/or
repetition of words; feeling of nausea; vomiting; agitation; and/or hallucination. All these complications
are temporary.
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I have had the opportunity to discuss the nitrous oxide in conjunction with my dental care, and have had an
opportunity to ask questions, and am fully satisfied and ready to proceed considering the answers I
received. I accept and understand that it is in my best interest to follow all instructions.
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I have informed the doctor of my complete medical history including any recent surgeries or changes in my
medical history involving lung, respiratory, ear infection or common cold. I also accept and understand that
I must notify the doctor of my present mental and physical condition.
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I accept and understand that I must notify the doctor if I: (I) am pregnant, (2) have sensitivity to any
medication, (3) have recently consumed alcohol, and/or (4) am presently on psychiatric mood-altering drugs
or other medications, and/or (5) any other conditions a reasonable health professional would want to know
before proceeding with treatment.
