• Date Format: MM slash DD slash YYYY
  • The purpose of this Informed Consent Form is to provide an opportunity for parents/guardian to understand and give permission for the use of Nitrous Oxide when provided along with dental treatment. Each item should be checked off after the parent or guardian has had the opportunity for discussion and questions.

    1. I accept and understand that Nitrous Oxide is commonly called laughing gas and provides relaxation, although, my child will be awake, fully conscious, and able to respond to directions.
    2. I accept and understand that the purpose of Nitrous Oxide is to make it more comfortable for my child to receive the necessary dental care with less pain and/or anxiety.
    3. I accept and understand that the use of Nitrous Oxide has limitations and risks and absolute success can NOT be guaranteed.
    4. I accept and understand that Nitrous Oxide will be administered by way of the inhalation route.
    5. I accept and understand that the alternatives to Nitrous Oxide are:
      • No Nitrous Oxide: The necessary procedure is performed under local anesthetic only
      • Oral Conscious Sedation: Sedation via liquid form that will decrease my child’s level of consciousness.
      • Intravenous (IV) Sedation/General Anesthetic: Commonly 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.
    6. The use of Nitrous Oxide has been fully explained to me, including all risks involved. I have been fully informed that temporary side effects may include, but are not exclusive of tingling in the fingers, toes, cheeks, lips; heaviness in their legs, followed by a lighter feeling; fits of uncontrollable laughter or giddiness; detachment or disassociation from environment may occur; lightweight or floating sensation; feeling of nausea; vomiting. All of these complications are temporary.
    7. I have had the opportunity to discuss the Nitrous Oxide in conjunction with my child’s dental treatment and have had an opportunity to ask questions, and am fully satisfied with the answers I received.
    8. I accept and understand that I must follow all recommended instructions for my child.
    9. I have informed the doctor of my child’s complete medical history including any recent surgeries or changes in medical history involving lung, respiratory, ear infection or common cold.
    10. I accept and understand that I must notify the doctor if my child: (1) has sensitivity to any medication, or (2) is presently on psychiatric mood altering drugs or other medications.
    11. I have reviewed, reviewed and understand the “Nitrous Oxide Overview” document

    IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OF THE PROPOSED TREATMENT OR PROCEDURE OR ANY OTHER QUESTIONS, PLEASE ASK THE DOCTOR BEFORE SIGNING THIS CONSENT FORM

  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.