I agree to follow all instructions provided to me by this office before and after the procedure, take medication(s) as prescribed, practice proper oral hygiene, keep all appointments, make return appointments if complications arise, and complete care. I will inform my doctor of any postoperative problems as they arise. My failure to comply could result in complications or less than optimal results.

If I have elected Mild, Moderate, or Deep Sedation (General Anaesthesia), I have not had anything to eat or drink for at least eight (8) hours prior to my procedure. I understand that doing otherwise maybe life-threatening. As instructed, I have taken my regular medications (blood pressure medications, antibiotics, etc.) and/or any medicine given to me by my doctor using only small sips of water.

I am accompanied by a responsible adult to drive me to and from the doctor’s office and he/she will stay with me after the procedure until I am recovered sufficiently to care for myself. I understand the drugs given to me for this procedure may not wear off for 24 hours.
During my recovery from anaesthesia, I agree not to drive, operate complicated machinery or devices, or make important decisions such as signing documents, etc.

I had sufficient time to read this document, understand the above statements, and have had a chance to get all my questions answered. By filling the below form, I acknowledge and accept the possible risks and complications of my anaesthetic and agree to proceed.