Pleasant Dreams Dental Anesthesia - Patient & Parent Consent Form

Patient & Parent Consent Form

Please complete the form below to authorize anesthesia treatment and confirm that you understand the procedure, possible risks, post-operative care instructions, and patient safety guidelines provided by our dental anesthesia team.
Patient / Guardian Information

First NameLast Name
Patient Name

First NameLast Name
Relationship to Patient
Date

MonthDayYear
Date
Name

First NameLast Name
Consent Statement

I hereby authorize and request the duly licensed Dental Anesthesiologist associated with Pleasant Dreams Dental Anesthesia to administer anesthesia for the planned dental procedure. I understand the anesthesia process, possible risks, benefits, side effects, and post-treatment care instructions. I acknowledge that anesthesia may involve complications including nausea, vomiting, sore throat, allergic reactions, bleeding, infection, breathing complications, and other rare medical risks. I understand that sedation and general anesthesia may affect coordination and judgment for up to twenty-four hours following treatment, and that responsible adult supervision is required during recovery. I acknowledge that all questions regarding the anesthesia procedure have been answered to my satisfaction and that I fully understand the treatment and consent voluntarily.
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