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    • Male:
    • Female:
  • Type of procedure: CONSCIOUS DENTAL SEDATION
  • Printed full name of Dentist: DR ALAN HOLLAND
  • I confirm that I have obtained a full medical history, and explained the treatment, its major and characteristic risk(s), available alternatives and the type of anaesthetic, if any regional/type of anaesthetic, sedation proposed, to the patient in terms which in my judgment are suited to the understanding of the patient and/or to one of the parents or guardian of the patient.
    • I agree:
  • PATIENT/PARENT/GUARDIAN. Please read this form and notes very carefully
  • If there is anything you do not understand about this explanation, or if you want more information, please ask the dentist. Please check all the information on the form is correct. If it is, and you understand the explanation, then sign the form.
    • Patient:
    • Parent:
    • Guardian:
  • I agree to what is proposed - which has been explained to me by the dentist named on this form - and to the use of the type of anaesthetic that I have been told about.
  • I understand that any procedure, in addition to the investigation or treatment described on this form, will only be carried out if it is necessary and in my best interests and can be justified for medical reasons.
  • I have told the dentist about any additional procedures I would wish not to be carried out straightaway without my having the opportunity to consider them first.
  • DO NOT SIGN THIS FORM UNLESS YOU HAVE READ AND UNDERSTAND ALL THE INFORMATION.
  • INSTRUCTIONS TO PATIENT. Please read and follow these very carefully.
  • The day before treatment:
  • - Telephone and confirm your intention to attend for sedation on the day of treatment
    - Take your routine medicines at the same time
    - Have only light meals and non-alcoholic drinks
    - Bring someone with you to the surgery to escort you home and care for you afterwards
  • After sedation and the following 24 hours:
  • - Do not travel alone, travel home with your escort, by car if possible
    - Do not drive or ride a bicycle
    - Do not operate machinery
    - Do not drink alcohol
    - Do not return to work or sign legal documents
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