I, hereby authorize and request duly licensed Dental Anesthesiologist.
Associated with Pleasant Dreams Dental Anesthesia, to perform the associated with Pleasant Dreams Dental Anesthesia, to perform the Anesthesia on

As previously explained to me and including any other procedure deemed necessary or advisable as a corollary to the planned anesthesia. I fully and knowingly consent, authorize, and request the administration of such anesthetic or anesthetics (local to general) by any route that is deemed suitable by the Dental Anesthesiologist. It is the understanding of the undersigned that the Dental Anesthesiologist will have full charge at all times of the administration and maintenance of the anesthesia, and this is an independent function from the surgery/dentistry.
The most frequent side effects of any intravenous anesthesia are drowsiness, nausea/vomiting, sore throat, and phlebitis. Most patients remain drowsy or sleepy for the remainder of the day following their surgery. As a result, coordination and judgment will be impaired for as long as twenty-four hours. It is recommended that children remain in the presence of a responsible adult during this period. Nausea and possible vomiting following anesthesia will occur in approximately 10-15% of patients. Phlebitis is a raised, tender, hardened, inflammatory response at the intravenous site, which usually resolves with local application of warm, moist heat. However, tenderness and a hard lump may be present up to a year.
I have been fully informed and understand that there are rare complications associated with anesthesia, including but not limited to: pain, hematoma, numbness, infection, swelling, bleeding, discoloration, nausea, vomiting, sore throat, allergic reaction to medications or materials, pneumonia, stroke, seizure, brain damage, heart attack, and death. I further understand and fully accept the risk that complications may require hospitalization. I have been made fully aware that the risks associated with local anesthesia, conscious sedation and general anesthesia vary. Of these three, local anesthesia is usually considered to have the least risk, and general anesthesia the greatest risk. However, it must be noted that local anesthesia alone sometimes is not appropriate for every patient and every procedure. However, various procedures, circumstances, and patients may warrant/require the need for sedation or general anesthesia.
For female patients: I understand that anesthetics, medications, and drugs may cause harm to an unborn child, regardless of term or trimester, leading to birth defects or spontaneous abortion. I accept full responsibility for informing the Dental Anesthesiologist of the possibility of being pregnant or confirming pregnancy, with the understanding that this will necessitate the postponement of anesthesia. I understand I must also inform the Dental Anesthesiologist if I am currently a nursing mother.
Since side effects of medications, drugs, anesthetics, and prescriptions may be increased by the use of alcohol, herbal supplements or other non-prescribed drugs, I have been advised of the necessity of direct parental/legal guardian/caregiver supervision of myself, my child, or the patient for twenty-four hours or longer until fully recovered from the effects of the anesthetic, medications and drugs that have been given to myself/my child or the patient. I have been advised of the necessity of direct parental supervision of my child for twenty-four hours following their anesthesia.
I accept any and all possible risks, side effects, and dangers of anesthesia. I acknowledge the receipt of and understand both the pre-operative and post-operative anesthesia instructions. It has been explained to me and I understand that there is no warranty and no guarantee as to any result and or cure. It is also understood that the anesthesia services are completely independent from the operating dentist’s procedure. I authorize the exchange of personal and medical information between the treating dentist’s office and Dental Anesthesiologist. I understand that personnel other than the dentist and staff may be allowed in the treatment room. The Dental Anesthesiologist assumes no liability from the surgery/dentistry performed while under anesthesia.
I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: 1) Conduct, plan, and direct treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly. 2) Obtain payment from third-party payers.

I have had the opportunity to ask questions about the proposed anesthesia for myself/my child/the patient, and I am fully satisfied with the information provided to me. I have been fully advised and completely understand the alternatives to sedation and general anesthesia.