Consent for Sedation

I give Dr. Lee consent to administer the sedative Versed (Midazolam) to my child in order to achieve a level of conscious sedation required to complete my child's dental treatment. The purpose of conscious sedation is to decrease my child's anxiety and to make the treatment less stressful. the effects of the medication have been discussed with me, as well as its alternatives such as general anaesthesia, and I am satisfied with the information.

I agree to comply with the following instructions that have been given and explained to me by Dr. Lee in order to maximize the safety and efficacy of the procedure:

  • I will bring my child at the scheduled time for administration of the sedative medication. Treatment usually starts about 30 minutes after.

  • I will ensure that my child will not eat or drink anything for 3 hours before the scheduled appointment. Efficacy increases on an empty stomach and serious medical complications, including death, could result if my child vomits during the procedure.

  • I will inform Dr. Lee if there are any changes in my child's health before treatment. I will mention any new medical conditions and/or medications begin taken that may affect the safe administration of the sedative medication.

  • I will make arrangements for my child to be directly supervised for at least 4 hours after the appointment until the sedative medication has worn off. I realize that my child may be prone to falls or other injuries during this time.

Dr. Lee has indiated to me that the sedative medication is mild and will be used at its lowest effective dose for my child's weight. I understand that individual reactions to medications cannot be predicted in advance because of individual variations. My child may fall asleep before or during their appointment and I understand that htis is generally not a concern. My child will not be allowed to leave unless they are awake. If there are any concerns or complications, oxygen may be administered and/or a pulse-oximeter monitor may be used in order to ensure maximum safety. Although rare (no reported problems in 10 years), post-operative complications may include allergic or paradoxical reactions (excitability, irritability, hostility). If my child experiences any unusual reactions, I will report it to Dr. Lee as soon as possible.

Instructions regarding the safe management of my child after the appointment will be explained to me by Dr. Lee before I leave. Written instructions may also be provided. If I have any questions or concerns, I will discuss them with Dr. Lee before I leave.

I have read and signed this consent form only after it has been thoroughly explained to me by Dr. Lee. I understand all of its contents. I agree to follow all of the instructions relating to the sedation and I have been given a copy of pre-operative instructions. Lastly, I understand that if these instructions are not followed, my child's appointment may be canceled.

LHSCPatients, Families & Visitors

Last Updated March 17, 2009 | © 2007, LHSC, London Ontario Canada