Nitrous Oxide Informed Consent
I, hereby authorize the above mentionedoffice’s provider(s)to perform nitrous oxide/oxygen conscious sedation for myself (or mychild/ward):
I hereby certify that I understand this authorization and the reasons for the above named sedative procedure and its associated risks. I am aware that the practice of dentistry is not an exact science. I acknowledge that every effort will be made in my (or my child’s) behalf for a positive outcome from sedation, but no guarantees have been made as to the result of the procedure authorized above.
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Signed by The Loving Dentist After Hours Care
Signed On: April 4, 2018
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Document Name: Nitrous Oxide Informed Consent
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